About the Course
Introduction
This CLE course will provide ERISA counsel and advisers guidance on direct contracting between employers and healthcare providers. The panel will discuss transparency rules impacting covered service providers, recent regulations and guidance under OBBBA, ERISA challenges associated with direct contracting for health benefits, practical and legal considerations in negotiating and drafting agreements between employers and healthcare providers, and other planning methods to ensure employer compliance with ERISA and other rules and regulations.
Description
The rise in healthcare costs has forced employers to consider contracting directly with healthcare providers to minimize expenses and improve the member experience associated with health benefits. Direct contracting arrangements can be complicated and require counsel and advisers to consider all legal ramifications to assist employers and providers.
Direct contracting agreements offer employers and healthcare providers an opportunity to work together, eliminating the need for some of the services provided by a third-party administrator (TPA). This approach can provide both parties with substantial benefits and a way to take on and understand the functions of the payor, administrator, and provider in the absence of a TPA. Furthermore, employers and providers negotiating direct contract agreements must comply with ERISA and other federal and state regulations.
Employer and provider arrangements inclusive of plan administrative services and the assumption of specific responsibilities by the provider are subject to ERISA rules governing service provider contracts and fiduciaries. These direct contracting arrangements must ensure that plan provisions and actions do not run afoul of the prohibited transaction rules or any fiduciary duties under ERISA.
Negotiations must involve careful consideration of the rules and limitations of HIPAA, the Affordable Care Act, ADA, OBBBA, and other regulations. Counsel must be knowledgeable of federal and state regulations to structure the direct contracting arrangement to secure the benefits to employers and providers and avoid compliance claims.
Listen as our panel discusses the federal and state law challenges associated with direct contracting for health benefits, practical and legal considerations in negotiating and drafting agreements, and planning methods to ensure compliance.
Presented By
Ms. Hunter has nearly 20 years of experience advising employers, health insurance issuers and third-party administrators on compliance with the full range of laws impacting health and welfare benefit plans, including tax, COBRA, ERISA and the Mental Health Parity and Addiction Equity Act. She has defended hundreds of matters challenging the administration of health plan benefits, the calculation of “out of network” provider payments, and compliance with the Mental Health Parity and Addiction Equity Act and the No Surprises Act. Ms. Hunter has represented Fortune 500 sports and entertainment clients in tax, ERISA, ACA and COBRA compliance issues for employee benefit plans as a result of corporate restructuring and spin-off transactions. She has successfully defended allegations of noncompliance with ERISA’s fiduciary and prohibited transaction rules, Mental Health Parity and Addiction Equity Act, and the Affordable Care Act in Department of Labor investigations for some of the largest employer-sponsored welfare plans in the country.
Ms. Morgan specializes in complex multi-state health insurance and health care regulatory challenges, drawing on more than fifteen years of experience both in-house and at top tier international law firms. She is a well-known expert in payor/provider issues and is adept in the intricacies of the Affordable Care Act (ACA) and state health insurance and managed care laws, and the interplay of the two. Additionally, Ms. Morgan has been part of industry-defining changes in digital health, data transparency and the post-CAA fiduciary landscape. She has advised health insurance and managed care clients on a broad range of regulatory issues, including state and federal mandated benefits; state and national health care reform; group health laws (e.g., extra-territorial applicability, withdrawal from group business); joint ventures; HIPAA and state conversion and continuation of coverage provisions; state privacy laws; utilization review requirements; company licensing; broker and agent issues; and applicability and interpretation of other relevant statutes and regulations. Ms. Morgan also provides regulatory advice regarding non-traditional healthcare models to third party administrators, consulting companies, and financial institutions, including negotiating with state insurance regulators to obtain insurance license exemptions for such models. She has a stellar record of positive outcomes when representing clients before state regulators in investigations and enforcement actions.
Mr. Shillcutt has deep experience in the areas of behavioral health, government and commercial reimbursement, and managed care due to his work at the Centers for Medicare & Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Centers for Disease Control and Prevention (CDC).
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This 90-minute webinar is eligible in most states for 1.5 CLE credits.
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Date + Time
- event
Thursday, October 8, 2026
- schedule
1:00 PM ET/10:00 AM PT
I. How direct contracting fits into an employer's overall health benefit strategy
A. Types of employer direct contracting arrangements
B. Opportunities for direct contracting to change the healthcare landscape
C. The mechanics of direct contracting between employers and healthcare providers
II. Ensuring compliance with ERISA, ACA, HIPAA, and other federal regulations
III. State law implications of employer and healthcare provider direct contracting
IV. Priority terms to consider in negotiating and structuring arrangements with providers for health benefits
V. Health plan design, documentation, and participant communications
VI. Best practices for employers in the administration of health plans from direct contracting arrangements
The panel will examine the following priority issues:
- Essential terms to include in direct contract negotiations
- Supporting compliance with ERISA-prohibited transaction rules
- Fiduciary duties of employer and provider in direct contracting arrangements under ERISA
- Plan design and drafting documentation and participant communications
- Structuring direct contracting arrangements to avoid potential claims and limiting provider discretion
- Compliance with HIPAA, ACA, ADA, and other regulations
- State regulatory challenges and considerations
- Best practices in health plan administration for employers and providers
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