Model Optimal Care warns self-funded plans on December gag clause filing

Model Optimal Care says self-funded health plan sponsors should review vendor contracts before signing the federal gag clause prohibition attestation due Dec. 31. The company argues the filing turns on contract language already on the books, leaving sponsors exposed if they have not read the agreements themselves.

Why it matters: - Self-funded health plans cover 67% of covered workers, 80% of workers at firms with 200 or more employees, and more than 160 million Americans. - The gag clause prohibition attestation is a legal filing tied to contract language, not a statement of intent. - Sponsors who sign without checking vendor agreements can take on compliance risk for language they may not have seen. - National health spending reached $5.7 trillion in 2025, and researchers estimate 25% to 30% of healthcare dollars are wasted.

What happened: - Model Optimal Care urged self-funded health plan sponsors to review service provider contracts before signing the annual gag clause prohibition compliance attestation. - The attestation is due to federal departments by Dec. 31. - The company said the sponsor who signs the filing is responsible for what the contracts actually say. - MOC Fiduciary Intelligence, Model Optimal Care’s AI platform at fiduciaryIQ.ai, reviews those agreements and flags restrictive language against the governing provision. - New users get a free one-month trial that includes one comprehensive fiduciary report and score and does not require a credit card.

The details: - The Consolidated Appropriations Act of 2021 added parallel gag clause provisions in Internal Revenue Code section 9824, ERISA section 724, and Public Health Service Act section 2799A-9. - The provisions took effect Dec. 27, 2020. - The rules bar a plan from entering agreements that restrict disclosure of provider-specific cost and quality information to participants, beneficiaries, sponsors, and referring providers. - The rules also bar restrictions on access to de-identified claims and encounter data on request. - The rules also bar limits on sharing that information with a business associate. - The first attestation was due Dec. 31, 2023. - Each year after that, a new attestation is due by Dec. 31 for the period since the prior filing. - The submission goes through the CMS HIOS portal. - Model Optimal Care said restrictive language can appear in data access sections, confidentiality clauses, audit provisions, or subcontracted network agreements. - Many self-funded plans let a third-party administrator file the attestation on their behalf. - Federal submission instructions say the filing can be delegated, but the responsibility cannot. - If a self-funded plan relies on a TPA and the TPA fails to submit, the plan violates the requirement. - MOC Fiduciary Intelligence reviews the administrative services agreement and amendments, PBM contract, stop-loss policy, network agreements, and the gag clause attestation itself. - The platform scores plans against 32 fiduciary indicators drawn from the Model Optimal Care framework, ERISA, and the CAA. - The score runs from 1 to 10 and includes citations to the governing provision behind each finding. - Users can ask questions in plain language and get answers cited to the relevant page in their own contracts. - In one Model Optimal Care sample review, the platform identified $5.23 million in savings opportunity and $1.24 million recoverable immediately. - Model Optimal Care said that sample figure is its own example, not independent research, and results vary by plan. - The free trial is available at fiduciaryIQ.ai. - The full feature set and scoring methodology are available at modeloptimalcare.com. - The framework behind the indicators appears in Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time, published by Manuscripts Press in May 2026.

Between the lines: - The company is framing the attestation as a contract-review problem, not a paperwork exercise. - The warning reflects a broader compliance gap: sponsors may sign filings based on TPA delegation while never checking the underlying agreements. - The focus on cited contract pages and governing provisions suggests Model Optimal Care is selling both compliance support and litigation-style documentation.

What's next: - Self-funded plan sponsors will need to complete this year’s attestation by Dec. 31. - Sponsors that use TPAs should confirm the filing was actually submitted and should verify the contract terms behind it. - Model Optimal Care is steering users to its trial, platform, and published framework for ongoing review of plan documents.

The bottom line: - For self-funded plans, the gag clause attestation may be as much about reading contracts as filing forms.