Opinion ID: 4549171
Heading Depth: 3
Heading Rank: 3

Heading: The Center’s Breach of Contract and

Text: Promissory Estoppel Claims As we confront this case at the motion to dismiss stage, the parameters of our analysis are shaped by our standard of review, and we must let the Center’s claims proceed if, “accept[ing] all factual allegations in the complaint as true and draw[ing] all reasonable inferences” in the Center’s favor, we find it has stated a claim “that is plausible on its face.” Menkes, 762 F.3d at 290 (citation omitted). As explained below, the Center has plausibly pleaded breach of contract and promissory estoppel claims that do not “relate to” ERISA plans under either of the two definitions: (1) the causes of action do not require impermissible “reference to” ERISA plans because they are not claims for benefits due under an ERISA plan and are not otherwise premised on ERISA plans; and (2) the claims do not have a “connection with” ERISA plans because they do not arise out of a relationship ERISA intended to govern, because they do not “interfere[] with nationally uniform plan administration,” and because holding these claims preempted would undermine ERISA’s stated purpose. 18
claims as pleaded do not require impermissible “reference to” ERISA plans Courts have devised a variety of formulations for the types of claims that make impermissible “reference to” ERISA plans. The Supreme Court has defined this class of claims to include not only those that “act[] immediately and exclusively upon ERISA plans,” Gobeille, 136 S. Ct. at 943 (citation omitted), but also, as relevant here, those “premised on” the plan,15 Ingersoll-Rand, 498 U.S. at 140. And claims in this second category, it has described variously as claims “where the existence of ERISA plans is essential to the law’s operation,” Gobeille, 136 S. Ct. at 943 (citation omitted); where the “court’s inquiry must be directed to the plan,” Ingersoll-Rand, 498 U.S. at 140; where “the existence of [an ERISA] plan is a 15 We treat the “premised on” test as a subset of the inquiry into whether a state law has an impermissible “reference to” ERISA plans, consistent with Supreme Court precedent. See Gobeille, 136 S. Ct. at 943 (defining “reference to” as covering those state laws that act “immediately and exclusively upon ERISA plans . . . or where the existence of ERISA plans is essential to the law’s operation” (alteration in original) (citation omitted)); Cal. Div. of Labor Standards Enf’t v. Dillingham Constr., N.A., 519 U.S. 316, 324–25 (1997) (concluding that “common-law cause[s] of action premised on the existence of an ERISA plan” are preempted under the “reference to” inquiry); cf. Nat’l Sec. Sys., Inc. v. Iola, 700 F.3d 65, 83–84 (3d Cir. 2012) (holding that claims “premised on” an ERISA plan have “a connection with or reference to such a plan” (citation omitted)). 19 critical factor in establishing liability,” id. at 139–40; and where “there simply is no cause of action if there is no plan,” id. at 140. From these variegated formulations we distill two overlapping categories of claims “premised on” ERISA plans: (a) claims predicated on the plan or plan administration, e.g., claims for benefits due under a plan, Menkes, 762 F.3d at 296 (citing Pilot Life Insurance Co. v. Dedeaux, 481 U.S. 41, 47– 48 (1987)); Kollman v. Hewitt Assocs., LLC, 487 F.3d 139, 150 (3d Cir. 2007), or where the plan “is a critical factor in establishing liability,” Ingersoll-Rand, 498 U.S. at 139–40; accord De Buono v. NYSA-ILA Med. & Clinical Servs. Fund, 520 U.S. 806, 815 & n.14 (1997); and (b) claims that “involve construction of [the] plan[],” 1975 Salaried Retirement Plan for Eligible Emps. of Crucible, Inc. v. Nobers, 968 F.2d 401, 406 (3d Cir. 1992), or “require interpreting the plan’s terms,” Menkes, 762 F.3d at 294. Below we address: (a) whether the breach of contract and promissory estoppel claims plausibly seek to enforce obligations independent of the plans rather than claims for benefits due under the plans or claims otherwise impermissibly tethered to the plans; (b) whether the claims as pleaded require impermissible construction or interpretation of the plans; and (c) Aetna’s arguments in support of preemption.
obligations independent of the plan Whether the Center seeks to enforce obligations independent of the plan turns on whether the parties agreed (i) that Aetna would provide payment for all services necessary to perform the respective surgeries, leaving only the amount of payment pegged to the terms of the plan; or (ii) that the scope 20 of coverage, as well as payment, would be limited to the terms of the plans—leaving open the possibility that some services would not be compensated at all. Aetna argues the latter, relying on Pilot Life Insurance Co. v. Dedeaux, 481 U.S. 41, 48 (1987), Menkes, 762 F.3d at 295– 96, and Kollman, 487 F.3d at 150. But those cases are inapposite. The common law claims in each were brought by plan participants or beneficiaries, alleging either that the insurer or plan administrator, or an agent thereof, had improperly processed or misrepresented the benefits due under the plan. Pilot Life, 481 U.S. at 43–44, 48; Menkes, 762 F.3d at 294–96; Kollman, 487 F.3d at 150. Those plaintiffs sought to enforce legal obligations flowing from the four corners of their ERISA plans. The claims here, on the other hand, arose precisely because there was no coverage under the plans for services performed by an out-of-network provider like the Center. In contrast to in-network providers whose relationship with Aetna is governed by a provider agreement that typically crossreferences the ERISA plan and limits payment to “covered services,” defined as those claims recognized as “medically necessary” under the terms of the relevant ERISA plan, see, e.g., Lone Star OB/GYN Assocs. v. Aetna Health Inc., 579 F.3d 525, 530 (5th Cir. 2009), out-of-network providers do not have pre-existing contractual relationships with the insurer. Thus, absent a separate agreement between Aetna and the Center, there was no obligation for the Center to provide services to the plan participants, no obligation for Aetna to pay the Center for its services, and no agreement that compensation would be 21 limited to benefits covered under the plan. 16 And the complaints allege such separate agreements here: As pleaded, the parties agreed that the Center would perform the surgeries and related medical care in exchange for payment from Aetna of a “reasonable amount” under J.L.’s plan and at the “highest in[-]network level” under D.W.’s plan for all component services (not merely those services covered under the terms of the plan). JA 59, 201–02. 16 We offer no opinion on the circumstances in which innetwork providers could bring state law claims for breach of contract arising out of the provider agreement or an equitable cause of action, such as promissory estoppel or quantum meruit, arising out of an insurer’s promise of payment without running afoul of section 514(a), which would depend on the content of the claims and the terms of the provider agreement. See, e.g., Pascack, 388 F.3d at 403; Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of Wis., Inc., 657 F.3d 496, 504–05 (7th Cir. 2011); Lone Star, 579 F.3d at 530; Blue Cross, 187 F.3d at 1050–54. Nor do we suggest that out-of-network providers are categorically exempt from section 514(a), with carte blanche to file suit for services rendered to plan participants. See, e.g., Access Mediquip, 662 F.3d at 386–87 (holding section 514(a) preempts unjust enrichment and quantum meruit claims premised on obligations imposed by ERISA plans rather than an independent promise of payment). Whether any agreement was reached with a provider, and the extent to which the terms of that agreement are so intertwined with the plan as to “relate to” an ERISA plan, are questions that depend on the facts and circumstances of the given case. 22 Aetna’s argument that the Center agreed to be bound by all terms and conditions of the plan—in effect, that it agreed to be paid as if it were an in-network provider—is simply not apparent on the face of the pleadings. In the case of J.L., the Center alleges that “Aetna contracted with [the Center] to provide multi-stage breast reconstruction surgery to J.L., along with related medical services, and to pay [the Center] a reasonable amount for those services according to the terms of the Plan.” JA 201–02. Accepting the pleadings as true and drawing all inferences in the Center’s favor, as we must at the motion to dismiss stage, we conclude that only the amount of payment and not the scope of services was to be determined in accordance with the terms of the plan; the services agreed to be compensated were all those required to perform J.L.’s procedure. The same holds true in D.W.’s case. We may reasonably infer from notes attached to the complaint that the Center identified at least eighteen distinct CPT 17 codes associated with D.W.’s surgery; the Center also alleges that a Center employee faxed D.W.’s clinical information to Aetna, requesting a “single case agreement” and was assured that if Aetna agreed to pay for the procedure it would instead pay the Center “at the highest in[-]network level,” JA 65, 67 (capitalization altered); and the Center alleges that an Aetna employee subsequently called the Center to confirm that Aetna “had agreed to approve 17 “CPT” stands for “Current Procedural Terminology” and is defined in D.W.’s plan as “the most recent edition of an annually revised listing published by the American Medical Association which assigns numerical codes to procedures and categories of medical care.” JA 81. 23 and pay” for the procedure, JA 59. These allegations plausibly support the inference that Aetna agreed to pay for all component services of D.W.’s surgery at the highest innetwork level. Aetna points to other evidence supporting a contrary inference. For example, it highlights the portion of the notes reflecting that it “do[es]n’t neg[otiate] [single case agreements] an[y] longer,” JA 65 (capitalization altered), and the language in its precertification letter 18—which was addressed to D.W. 18 The same day Aetna allegedly confirmed to the Center that it had approved D.W.’s surgery and would make payment at the “highest in[-]network level,” Aetna also sent the Center a copy of a precertification letter, addressed to its insured, D.W., identifying fourteen services that had been approved. JA 59. The letter stated, among other things, that “[y]our plan does not have out-of-network benefits”; that coverage for the fourteen services was “approved, subject to the requirements of this letter”; and that approval was “at an in-network benefit level,” subject to “any applicable dollar limits.” Defs.’ Mot. to Dismiss Ex. 2, ECF No. 12-2, at 1, 7–8. It also advised that reimbursement would “be based on standard coding and bundling logic and any mutually agreed upon contracted or negotiated rates, subject to any and all copays or coinsurance requirements”; that D.W. would “be responsible . . . for innetwork cost-sharing requirements”; and that D.W. “should refer to the plan document to determine exclusions and limitations under the plan.” Id. at 1, 7. Though the precertification letter is extraneous to the pleadings, we consider it because it is integral to the pleadings. See Angstadt v. Midd-W. Sch. Dist., 377 F.3d 338, 342 (3d Cir. 2004). 24 but also copied to the Center—stating that “the member’s eligibility for coverage under the plan [has been verified]” and that reimbursement would be based on “standard coding and bundling logic and any mutually agreed upon contracted or negotiated rates,” Defs.’ Mot. to Dismiss Ex. 2, ECF No. 12-2, at 1, 7. From this evidence, Aetna argues we may plausibly infer that the agreement was for the benefits and not merely the rate of payment set forth in the plan. Be that as it may, it does not render the Center’s inferences implausible: The notes go on to document other statements supporting the Center’s position, and Aetna concedes the precertification letter was drafted not for the benefit of the Center, but for the benefit of its insured, D.W. In short, even assuming a different inference is also plausible, at the motion to dismiss stage, we must view the allegations in the light most favorable to the Center and draw all reasonable inferences in the Center’s favor. When we do so, the claims as pleaded are not for benefits due under the plans. Nor are the claims otherwise impermissibly predicated on the plan or plan administration. Because, as alleged, it is Aetna’s oral offers or oral promises (as the case may be) rather than the terms of the plan that define the scope of Aetna’s duty, the plans are not “critical factor[s] in establishing liability.” 19 See Ingersoll-Rand, 498 U.S. at 139–40. 19 To establish its breach of contract claims, the Center may put forth evidence of oral offers and acceptances giving rise to non-plan-based duties, see Williams v. Vito, 838 A.2d 556, 560 (N.J. Super. Ct. Law. Div. 2003) (“[A]bsent a statute to the contrary, an oral offer and acceptance constitutes a binding agreement . . . .”), and evidence of its performance as valuable consideration for that binding agreement, see Martindale v. 25
interpretation or construction of ERISA plans Expounding on the scope of this class of preempted claims, we have clarified that a claim that “turns largely on legal duties generated outside the ERISA context,” and “requires only a cursory examination of the plan” is “not the sort of exacting, tedious, or duplicative inquiry that the preemption doctrine is intended to bar.” Iola, 700 F.3d at 85 (internal quotation marks and citation omitted). Aetna argues that the Center’s claims are so enmeshed with the plans as to require interpretation or construction of the plans. But assuming the Center can establish an agreement to pay for all component services, it is not apparent from the pleadings why more than a cursory review of either J.L.’s or D.W.’s plan would be required to establish “a reasonable amount . . . according to the terms of the Plan,” JA 201–02, or the “highest in[-]network level,” JA 59, for each service. Sandvik, Inc., 800 A.2d 872, 878–79 (N.J. 2002) (citation omitted); see also Restatement (Second) of Contracts § 71 (1981). The same holds true for the promissory estoppel claims. As alleged, the plans are not “critical,” De Buono, 520 U.S. at 815, to the demonstration of “(1) a clear and definite promise; (2) made with the expectation that the promisee will rely on it; (3) reasonable reliance; and (4) definite and substantial detriment,” Toll Bros., Inc. v. Bd. of Chosen Freeholders, 944 A.2d 1, 19 (N.J. 2008). 26 In neither its briefing nor at oral argument did Aetna explain why these determinations of in-network payment rates would be particularly complex or require careful study of the intricacies of the plans. To the contrary, the reasonable inference from the pleadings is that, consistent with representations Aetna has made in other cases, the determination is as simple as checking the “usual, customary, and reasonable (‘UCR’) rate . . . based on an industry-standard schedule” for the services in question, see, e.g., McCulloch Orthopaedic Surgical Servs., PLLC v. Aetna Inc., 857 F.3d 141, 144 (2d Cir. 2017), or reviewing the fee schedule attached to Aetna’s in-network provider agreements, see Lone Star, 579 F.3d at 530. The former would be precisely the type of “cursory examination of the plan” that we have held does not trigger express preemption, see Iola, 700 F.3d at 85, and the latter would not require any examination of the plan, but only of the fee schedule Aetna uses with its providers, see Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of Wis., Inc., 657 F.3d 496, 504–05 (7th Cir. 2011). Such inquiries do not entail “the sort of exacting, tedious, or duplicative inquiry that the preemption doctrine is intended to bar.” Iola, 700 F.3d at 85.
Aetna offers essentially two counterarguments. Neither is persuasive. First, it contends that any reference to an ERISA plan in the calculation of damages—no matter the degree of examination required—triggers express preemption. But that argument is belied by Iola, where we held that misrepresentation claims based on statements made prior to the adoption of an ERISA 27 plan were not preempted even though establishment of those claims, and in turn the court’s assessment of damages, “require[d] . . . a cursory examination of the plan provisions,” including “whether the representations . . . were at odds with the plan itself, or with the plaintiffs’ understanding of the benefits afforded by the plans.” 700 F.3d at 85. Likewise, the Center’s core contention—that oral promises of payment induced it to act to its detriment—and the proof that would be required involve, at most, only a “cursory examination” of plan provisions “turn[ing] largely on legal duties generated outside the ERISA context.” Id. (internal quotation marks and citation omitted). 20 Second, Aetna argues that the Center’s claims are premised on ERISA plans because the plans required preapproval of 20 The sole authority on which Aetna relies, Nobers, is also readily distinguishable. Nobers held common law claims preempted because the calculation of damages required “construction of [an] ERISA plan[].” 968 F.2d at 406. But the Nobers plaintiffs were a class of employees who alleged that “they [sh]ould have received substantially greater pension and related benefits,” id. at 404, assessing damages therefore would have required benefit calculations that “sit[] within the heartland of ERISA,” Iola, 700 F.3d at 84; see Kollman, 487 F.3d at 149–50. The Center, on the other hand, does not allege that Aetna’s liability flows from its promise to provide J.L. and D.W. benefits under their ERISA plans; it alleges “a separate promise that references various [ERISA] benefit plans, none of which directly applies to [the Center] by its terms, as a means of establishing the value of that promise,” Stevenson v. Bank of N.Y. Co., 609 F.3d 56, 60–61 (2d Cir. 2010). 28 J.L.’s and D.W.’s surgeries. Aetna places great weight on this point, presumably because before concluding that an out-ofnetwork provider’s state law claims were not completely preempted by section 502(a), 21 the Second Circuit in McCulloch observed that the provider “was not required by the plan to pre-approve coverage for the surgeries that he performed.” 857 F.3d at 150–51. Of course, we are not bound by this out-of-circuit precedent, but Aetna misapprehends it in any event. In context, the McCulloch court was contrasting a prior case where it had found that the preapproval required of innetwork providers under the plan was “inextricably intertwined with the interpretation of Plan coverage and benefits,” Montefiore Med. Ctr. v. Teamsters Local 272, 642 F.3d 321, 330, 332 (2d Cir. 2011); see McCulloch, 857 F.3d at 150–51. Moreover, the court went on to explain that when it came to out-of-network providers, the ERISA plan imposed a duty only on the plan participant or beneficiary to seek precertification; as they are neither parties to the plan nor parties to an innetwork provider agreement, there was no corresponding duty on out-of-network providers. McCulloch, 857 F.3d at 150–51, 151 n.7. Rather, the provider there, like the Center, “called Aetna for [its] own benefit to decide whether [it] would accept or reject a potential patient who sought [its] out-of-network 21 Complete preemption is a separate, jurisdictional doctrine that in this context arises out of section 502(a). Davila, 542 U.S. at 210. Under this doctrine, if a litigant could have brought a cause of action under section 502(a) and if “no other independent legal duty . . . is implicated by [the] defendant’s actions,” the claim is federal in nature. Id. 29 services,” id. at 151, and the plan “simply provide[d] the context for” the out-of-network provider’s claim, id. at 149. In short, McCulloch, if anything, weighs against express preemption here, as does other case law: The mere fact that a claim arises against the factual backdrop of an ERISA plan does not mean it makes “reference to” that plan. See Travelers, 514 U.S. at 661 (“[P]re-emption does not occur . . . if the state law has only a tenuous, remote, or peripheral connection with covered plans . . . .” (second alteration in original) (citation omitted)); Iola, 700 F.3d at 85 (holding section 514(a) does not preempt misrepresentation claims arising out of statements made about an ERISA plan prior to the plan’s adoption); Dishman v. UNUM Life Ins. Co. of Am., 269 F.3d 974, 983–84 (9th Cir. 2001) (concluding that state law claims were not expressly preempted even though there was “clearly some relationship” to an ERISA plan); see also Morris B. Silver M.D., Inc. v. Int’l Longshore & Warehouse Union, 206 Cal. Rptr. 3d 461, 472 (Ct. App. 2016) (“[T]he fact [that] an ERISA plan is an initial step in the causation chain, without more, is too remote of a relationship with the covered plan to support a finding of preemption.”). Because the Center’s claims, as pleaded, neither seek benefits due under the plans, nor require more than a cursory examination of the plans, they do not make impermissible “reference to” the plans. 30
claims do not have a “connection with” ERISA plans State laws have a “connection with” ERISA plans if they “govern, or interfere with the uniformity of, plan administration,” Gobeille, 136 S. Ct. at 943, or if the “acute, albeit indirect, economic effects of the state law force an ERISA plan to adopt a certain scheme of substantive coverage or effectively restrict its choice of insurers,” id. (internal quotation marks and citation omitted). In making this assessment, we consider “the objectives of the ERISA statute as a guide to the scope of the state law that Congress understood would survive and the nature of the effect of the state law on ERISA plans.” Id. (internal quotation marks and citation omitted); accord Menkes, 762 F.3d at 294. Distilling these tests, we and other Courts of Appeals focus primarily on whether claims (a) “directly affect the relationship among the traditional ERISA entities—the employer, the plan and its fiduciaries, and the participants and beneficiaries,” Mem’l Hosp., 904 F.2d at 245, 248 (citing Mackey v. Lanier Collection Agency & Serv., Inc., 486 U.S. 825, 833 (1988)); Access Mediquip, 662 F.3d at 385–86 (same); (b) interfere with plan administration, Menkes, 762 F.3d at 295–96; Access Mediquip, 662 F.3d at 385; or (c) undercut ERISA’s stated purpose, Iola, 700 F.3d at 84–85; Kollman, 487 F.3d at 149. As pleaded, it is plausible that the Center’s claims do not implicate any of these avenues for an impermissible “connection with” ERISA plans. 31 a. The claims plausibly arise out of a relationship that ERISA did not intend to govern ERISA governs relationships among “the employer, the plan and its fiduciaries, and the participants and beneficiaries.” Mem’l Hosp., 904 F.2d at 245 (citing Mackey, 486 U.S. at 833); accord Access Mediquip, 662 F.3d at 385–86. As our sister circuits have recognized, ERISA struck a “bargain” between the interests of participants and beneficiaries on the one hand and insurers on the other: Section 502(a) created federal causes of action that allow plan participants and beneficiaries to enforce ERISA’s mandates, and section 514(a) limits potential sources of plan liability, providing employers and plan administrators with some measure of security. See, e.g., Mem’l Hosp., 904 F.2d at 249. Critically, however, out-of-network healthcare providers “were not . . . party to this bargain.” Id. Absent the assignment of benefits, a healthcare provider may not pursue its own section 502(a) cause of action, N. Jersey Brain & Spine Ctr., 801 F.3d at 372, and section 514(a) works predominately to the benefit of insurers, employers, and plan participants by reducing compliance and litigation costs and thereby increasing the resources employers have to invest in providing high-quality plans for their employees, Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355, 379 (2002). Health care providers such as the Center orbit the periphery of this bargain, but their rights and remedies are not delineated in ERISA’s substantive or remedial provisions. For this reason, the Courts of Appeals have overwhelmingly held that claims akin to the Center’s are not expressly preempted because, as pleaded, they arise out of a 32 relationship ERISA did not intend to govern at all. See Access Mediquip, 662 F.3d at 385–86; In Home Health, Inc. v. Prudential Ins. Co. of Am., 101 F.3d 600, 605–06 (8th Cir. 1996); Meadows v. Emp’rs Health Ins., 47 F.3d 1006, 1009– 11 (9th Cir. 1995); Lordmann Enters., Inc. v. Equicor, Inc., 32 F.3d 1529, 1533–34 (11th Cir. 1994); see also Franciscan Skemp Healthcare, Inc. v. Cent. States Joint Bd. Health & Welfare Tr. Fund, 538 F.3d 594, 599–601 (7th Cir. 2008) (citing this line of cases approvingly); Gerosa v. Savasta & Co., 329 F.3d 317, 324 (2d Cir. 2003) (collecting cases). Indeed, the only circuit to reach the opposite conclusion is the Sixth Circuit in Cromwell v. Equicor-Equitable HCA Corp., 944 F.2d 1272 (6th Cir. 1991), which has been aptly criticized as a “poorly reasoned outlier in the face of the strong trend in the bulk of the cases considering healthcare-provider claims,” Franciscan Skemp, 538 F.3d at 601. 22 The Department of Labor, too, has noted the “overwhelming and persuasive consensus” that state law claims brought by third-party health 22 The Cromwell majority held that the provider’s state law claims were all brought “as grounds for the recovery of benefits from the [ERISA] plan for health care services rendered.” 944 F.2d at 1276 (emphasis added). But it painted with too broad a brush: While this may have been true for the breach of contract and good faith claims that were brought pursuant to an assignment of benefits and for breach of the ERISA plan itself, it was not for the promissory estoppel and negligent misrepresentation claims, where the legal duty allegedly breached arose not from the plan but from oral promises made by plan administrators and where the healthcare providers were seeking damages for reliance upon those promises. See id. at 1283–85 (Jones, J., dissenting). 33 care providers against ERISA plan administrators implicate “separate relationship[s]” from those ERISA was intended to govern and thus, generally, “are not . . . preempted under section 514.” 23 We join that consensus today and conclude that the relationship between the Center, an out-of-network provider, and Aetna, as plan administrator, does not itself create an impermissible “connection with” the plans in this case. 23 Brief for the Secretary of Labor as Amicus Curiae in Support of Plaintiff-Appellant at 23, 25, McCulloch Orthopaedic Surgical Servs., PLLC v. United Healthcare Ins. Co., No. 15-2144 (2d Cir. Oct. 22, 2015), https://www.dol.gov/sol/media/briefs/mcculloch_2015-1022.pdf. While the Secretary’s brief is properly the subject of judicial notice, see Vanderklok v. United States, 868 F.3d 189, 205 n.16 (3d Cir. 2017), it is entitled to only Skidmore deference, both because it is a litigation position, Smiley v. E.I. Dupont de Nemours & Co., 839 F.3d 325, 329 (3d Cir. 2016), and because “[w]e do not defer to an agency’s view concerning preemption, but such views . . . are entitled to respect . . . to the extent [they] ha[ve] the power to persuade,” Shuker v. Smith & Nephew, PLC, 885 F.3d 760, 773 n.11 (3d Cir. 2018) (first and second alterations added) (internal quotation marks omitted) (quoting Sikkelee v. Precision Airmotive Corp., 822 F.3d 680, 693–94 (3d Cir. 2016)); see also Skidmore v. Swift & Co., 323 U.S. 134, 140 (1944). 34 b. As pleaded, the claims do not interfere with the administration of either plan Aetna next argues the Center’s claims have a “connection with” the plans because litigating those claims would impermissibly interfere with plan administration and have severe economic consequences for plan coverage and insurer choices. Specifically, Aetna urges us to adopt the view of the Fifth Circuit in Access Mediquip, 662 F.3d at 386–87, that litigating the provider’s unjust enrichment and quantum meruit claims in that case would open the floodgates for any healthcare provider to challenge the compensation it receives under an ERISA plan. We decline Aetna’s suggestion because those floodgate concerns are inapplicable. The unjust enrichment and quantum meruit claims in Access Mediquip “depend[ed] on [the provider’s] assertion that without its services the patients’ ERISA plans would have obliged [the insurer] to reimburse a different provider for the same services.” 662 F.3d at 378. Those claims arose, in other words, not from any independent agreement, oral or otherwise, to provide services for payment, but from the obligations under the plan. For that reason, the provider sought recovery “only to the extent that the patients’ ERISA plans confer on their participants and beneficiaries a right to coverage for the services provided.” Id. at 386 (emphasis added). Here, by contrast, the Center’s breach of contract and promissory estoppel claims do not allege that J.L.’s and D.W.’s plans covered the services at all; instead, the Center alleges that Aetna must pay the costs of these services only because, and to the extent, it promised the Center that it would. See Morris B. 35 Silver, 206 Cal. Rptr. 3d at 472 n.16 (2016) (distinguishing Access Mediquip on this ground). The Center’s claims, in other words, are much more analogous to the misrepresentation claim that the Access Mediquip court held was not preempted because it arose out of an obligation independent from the plan. 662 F.3d at 384–85. And like that claim, the Center’s claims— at least on the face of the complaints—would merely result in a one-time payment of damages based on the specific agreement reached by the parties that does not impermissibly interfere with plan administration. Cf. Iola, 700 F.3d at 85 (holding that assessing damages against insurers “for pre-plan fraud does not affect the administration or calculation of benefits” (citation omitted)). As a result, allowing these claims does not impermissibly interfere with plan administration. Nor does it preclude insurers like Aetna (or providers like the Center) from minimizing the risk of unanticipated liability by formalizing their agreements and thus identifying both the particular services to be provided and the dollar amounts to be paid (or particular fee schedule to be used) for those services. What is more, Aetna’s insistence that there will be staggering downstream economic effects if these claims are allowed to proceed is belied by experience. For the past thirty years, since the Fifth Circuit’s seminal decision in Memorial Hospital, our sister circuits have held that claims akin to the Center’s are not expressly preempted, and, lo and behold, the sky has not fallen. See, e.g., Access Mediquip, 662 F.3d at 384–86; In Home Health, 101 F.3d at 604–06; Meadows, 47 F.3d at 1009–11; Lordmann, 32 F.3d at 1533–34; see also Franciscan Skemp, 538 F.3d at 601. In following suit today, we foster the coherence and “uniform[ity]” in ERISA law that the Supreme Court has encouraged. See Gobeille, 136 S. Ct. at 944. 36 c. Holding the claims preempted at this phase of the litigation would undercut ERISA’s purposes In evaluating claims’ “connection with” ERISA plans, the Supreme Court has instructed that we must consider “the objectives of the ERISA statute as a guide to the scope of the state law that Congress understood would survive and the nature of the effect of the state law on ERISA plans.” Gobeille, 136 S. Ct. at 943 (internal quotation marks and citation omitted). Here, those considerations support the conclusion that the Center’s claims, as pleaded, are not preempted. ERISA’s “principal object” was “to protect plan participants and beneficiaries.” Id. at 946 (quoting Boggs v. Boggs, 520 U.S. 833, 845 (1997)); see 29 U.S.C. § 1001(b) (highlighting “the interests of participants in employee benefit plans and their beneficiaries”). For those parties, who benefit from both ERISA-created rights and ERISA’s civil enforcement scheme, it makes good sense that a state law remedy that “duplicates, supplements, or supplants” the remedies set forth in section 502(a) runs afoul of “clear congressional intent to make” those remedies exclusive, triggering conflict preemption. Aetna Health Inc. v. Davila, 542 U.S. 200, 209 (2004). The resulting circumscription of remedies available to participants and beneficiaries was part and parcel of the bargain struck in establishing ERISA’s substantive guarantees. But protection of plan participants and beneficiaries is not advanced by extending express preemption to out-of-network providers and limiting their universe of remedies to those 37 outlined in section 502(a). In cases such as D.W.’s, where a plan contains an anti-assignment provision, express preemption would leave the provider with only one option: Sue the patient, hoping that the patient either is willing or able to pay significant, unexpected costs or has the interest and wherewithal to file suit against the insurer under section 502(a). 24 Neither circumstance, however, is likely to compensate the provider for the harm it suffered in reliance on the insurer’s promise of payment. The first will rarely come to pass and even more rarely at the full amount to which the provider and insurer agreed; the second would be limited in any event to the benefits to which the patient was entitled under the plan, not the full payment promised by the insurer. And the prospect of suing patients to eventually recover from their insurers is unpalatable, to say the least, from a reputational and business development standpoint, not to mention the damage it would cause to the doctor–patient relationship. Although Congress has narrowed the universe of remedies available to participants and beneficiaries, we will not assume 24 At oral argument, Aetna suggested that insurers might allow providers to seek an assignment of benefits notwithstanding an anti-assignment provision in the plan. But it cites no authority suggesting this practice is common, let alone required; nor does it offer a sound reason for leaving the payment of providers’ compensation to the whim of insurers. Quite the contrary, as our sister circuits have recognized, and as we explore in more detail below, providers will likely respond to this uncertainty by either refusing to treat patients or imposing barriers to care that will ultimately harm patients. E.g., Mem’l Hosp., 904 F.2d at 247–48. 38 that it intended simultaneously to strip healthcare providers, such as the Center, of any meaningful remedy, particularly where the guidance from the Supreme Court, though limited, indicates otherwise. See Mackey, 486 U.S. at 834 (1988) (holding that ERISA does not preempt “state-law methods for collecting money judgments . . . [because] otherwise, there would be no way to enforce such a judgment won against an ERISA plan”). 25 Indeed, if anything, that would disserve ERISA’s statutory objectives. To accept Aetna’s argument would be to accept the troubling proposition that an out-of-network provider’s right to 25 See also Tr. of the AFTRA Health Fund v. Biondi, 303 F.3d 765, 782 (7th Cir. 2002) (Because ERISA “does not provide any mechanism for plan administrators or fiduciaries to recoup monies defrauded from employee benefit trust funds by plan participants, garden-variety state-law tort claims must, as a general matter, remain undisturbed . . . .”); Gerosa, 329 F.3d at 329–30 (concluding it is “implausible that Congress intended” a result that “would leave [an] affected plan with no means for making up its shortfalls”); Hospice of Metro Denver, 944 F.2d at 755 (reasoning that “if health care providers have no recourse under ERISA or under state law, there will be reluctance on the part of health care providers to extend care without prepayment”); In Home Health, 101 F.3d at 606–07 (“If providers have no recourse under either ERISA or state law . . . , [they] will be understandably reluctant to accept the risk of non-payment, and may require up-front payment by beneficiaries—or impose other inconveniences—before treatment will be offered.” (quoting Mem’l Hosp., 904 F.2d at 247–48)). 39 recourse may be bargained away by insurers and plan participants in the terms of an ERISA plan to which the provider is not a party and which it likely has had no opportunity to review before it provides care. It would in effect allow insurers to illegitimately supplement their provider network by making promises of payment to induce the provision of services, safe in the knowledge that those out of network would have no recourse for breach of those promises. The consequence, as recognized by other Courts of Appeals, would be for providers to begin to require up-front payments from patients or to “deny care or raise fees to protect themselves against the risk of noncoverage.” Lordmann, 32 F.3d at 1533; accord In Home Health, 101 F.3d at 606–07; Mem’l Hosp., 904 F.2d at 247–48. That is a far cry from “protect[ing] plan participants and beneficiaries.” Gobeille, 136 S. Ct. at 943 (citation omitted). “[T]he objectives of the ERISA statute,” id., thus also indicate the Center’s claims do not have an impermissible “connection with” the ERISA plans.