530 U.S. 211 (2000)
Cynthia Herdrich was covered by Carle Clinic Association, P. C., Health Alliance Medical Plans, Inc., and Carle Health Insurance Management Co., Inc., functioning as a health maintenance organization organized for profit whose physician owners provided prepaid medical services to participants under contracts with employers such as State Farm Insurance Company.1
A Carle physician, Lori Pegram, examined Herdrich for pain in the midline area of her groin and six days later discovered a six by eight centimeter inflamed mass in her abdomen, yet decided against ordering an ultrasound at a local hospital and instead scheduled the procedure for eight days later at a Carle facility more than fifty miles away.2 Herdrich’s appendix ruptured before the appointment, causing peritonitis.3
Herdrich sued Pegram and Carle in state court for medical malpractice and later added counts for state-law fraud that led to removal of the case to federal court.4 After the district court granted summary judgment on one fraud count, Herdrich amended the remaining count to allege an inherent breach of ERISA fiduciary duty arising from the HMO’s incentive structure rewarding physicians for limiting care.5 The district court dismissed the ERISA claim.6 A jury awarded Herdrich thirty-five thousand dollars on the malpractice claims, and the Court of Appeals for the Seventh Circuit reversed the dismissal of the ERISA count.7
The Supreme Court granted certiorari to review the Seventh Circuit’s decision.8
Whether treatment decisions made by a health maintenance organization, acting through its physician employees, are fiduciary acts within the meaning of the Employee Retirement Income Security Act of 1974?9
ERISA defines a fiduciary as one who exercises discretionary authority or responsibility in the administration of a plan, 29 U.S.C. § 1002(21)(A)(iii), and requires fiduciaries to discharge duties solely in the interest of participants and beneficiaries, 29 U.S.C. § 1104(a)(1).10 Mixed eligibility and treatment decisions by HMO physicians, however, are not fiduciary acts because they involve medical judgments rather than plan administration or asset management.11
No. The established facts demonstrate that Cynthia Herdrich received coverage through the Carle HMO under her husband’s State Farm plan.12 Dr. Lori Pegram’s decision to delay an ultrasound and direct it to a distant Carle facility constituted a mixed eligibility and treatment determination that blended medical judgment with coverage consequences.13 Under the rule, such decisions do not qualify as fiduciary acts because they resemble ordinary medical practice rather than the management or administration of plan assets that ERISA fiduciary duties target.14 The facts further show that Herdrich amended her complaint to allege an inherent breach arising from Carle’s year-end profit distributions to physician owners.15 The district court dismissed the ERISA claim. A jury awarded Herdrich thirty-five thousand dollars on the malpractice claims, and the Court of Appeals for the Seventh Circuit reversed the dismissal of the ERISA count. The Seventh Circuit’s reversal treated these mixed decisions as fiduciary.16 Application of the rule to the named facts confirms they fall outside ERISA fiduciary responsibility because Congress did not intend to federalize malpractice claims through the fiduciary label.17
The rule elements confirm this result. First, ERISA fiduciary status attaches only to the extent a person acts in a fiduciary capacity.18 The facts establish that Pegram’s actions were treatment decisions inextricably intertwined with eligibility determinations, not pure administrative acts such as determining whether appendicitis was covered.19 Second, the common-law trust analogy invoked by the rule does not extend to physicians who both decide and consume plan resources through their medical judgments.20 Third, recognizing fiduciary liability here would convert every HMO mixed decision into a federal claim, a result the rule precludes because it would undermine congressional policy favoring HMOs without any concrete statutory command.21
Treatment decisions made by a health maintenance organization, acting through its physician employees, are not fiduciary acts within the meaning of ERISA.22