A 5046

ASSEMBLY, No. 5046
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED MAY 11, 2026
Sponsored by:
Assemblyman� MICHAEL VENEZIA
District 34 (Essex)
SYNOPSIS
���� Requires health care claims experience data to be
shared with local governments.
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act concerning local government claims experience
data, amending and supplementing P.L.2013, c.189, and supplementing P.L.2019,
c.274.
���� Be It
Enacted by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� Section 1 of P.L.2013,
c.189 (52:14-17.37a) is amended to read as follows:
���� 1.��� The State Health
Benefits Program and School Employees Health Benefits Program shall
provide at no cost to the requestor[,
and not more than once in a 24-month period,]
complete claims experience data to a public employer other than the State that
participates in the [State
Health Benefits Program]
program and makes a written request for its claims experience
information, including loss reports and large claims data.� The [State Health
Benefits Program]
program shall provide the information in an electronic and manual format
to the participating public employer who has made a written request for its
information, within 60 days of the receipt of the written request made by the
public employer.� Notwithstanding the above, the [State Health Benefits Program] program
shall issue claims experience data only in a manner that complies with the
privacy requirements of the federal Health Insurance Portability and
Accountability Act of 1996, Pub. L.104-191, and related regulations.
(cf: P.L.2013, c.189, s.1)
���� 2.��� Section 2 of P. L.2013,
c.189 (40A:10-38.15) is amended to read as follows:
���� 2.��� A joint insurance fund
established pursuant to P.L.1983, c.372 (C.40A:10-36 et seq.) and subsection e.
of section 1 of P.L.1979, c.230 (C.40A:10-6) for the purposes of providing
health benefits or health insurance coverage shall provide at no cost to the
requestor[,
and not more than once in a 24-month period,]
complete claims experience data to a public employer that participates in the
joint insurance fund and makes a written request for its claims experience
information, including loss reports and large claims data.� The joint insurance
fund shall provide the information in an electronic and manual format to the
participating public employer who has made a written request for its
information, within 60 days of the receipt of the written request made by the
public employer.� Notwithstanding the above, the joint insurance fund shall
issue claims experience data only in a manner that complies with the privacy
requirements of the federal Health Insurance Portability and Accountability Act
of 1996, Pub.L.104-191, and related regulations.
(cf: P.L.2013, c.189, s.2)
���� 3.��� (New section)� a.� A carrier,
third-party administrator, or other entity that provides health benefits
coverage to employees of a local unit shall provide complete claims experience
data to a local unit employer that makes a written request for its claims
experience information, including loss reports and large claims data.� The
carrier, third-party administrator, or other entity shall provide the
information in an electronic and manual format within 60 days of the receipt of
the request at no cost to the employer.� The carrier, third-party administrator,
or other entity shall issue claims experience data only in a manner that
complies with the privacy requirements of the �Health Insurance Portability and
Accountability Act of 1996,� Pub.L.104-191.
���� b.��� A carrier, third-party administrator,
or other entity that violates this section shall be subject to a penalty in an
amount not exceeding $5,000.� Each day the carrier, third-party administrator,
or other entity is in violation shall constitute a separate violation.� The
penalty may be recovered in a summary proceeding by the Department of Banking
and Insurance pursuant to the "Penalty Enforcement Law of 1999,"
P.L.1999, c.274 (C.2A:58-10 et seq.).
���� The Department of Banking and
Insurance shall investigate and enforce violations of this section.� A local
unit employer may refer a violation of this section to the department.� The
department shall compel disclosure of claims experience data required to be
disclosed pursuant to subsection a. of this section if a violation is found.
���� c.���� For the purposes of
this section, "local unit" means any municipal government, county
government, board of education, fire or other special district that raises
or relies upon property tax revenue as a budget revenue, or joint meeting, or any
board, commission, or agency thereof.
���� 4.��� (New section)� a.� A pharmacy
benefits manager that provides prescription drug benefits to employees of a local
unit shall provide complete prescription claims experience data to a local unit
employer that makes a written request for its claims experience information,
including claim-level prescription data, rebate amounts received by the
pharmacy benefits manager, and a disclosure of spread pricing practices.� The pharmacy
benefits manager shall provide the information in an electronic and manual
format within 60 days of the receipt of the request at no cost to the
employer.� The pharmacy benefits manager shall issue claims experience data
only in a manner that complies with the privacy requirements of the �Health
Insurance Portability and Accountability Act of 1996,� Pub.L.104-191.
���� b.��� A pharmacy benefits
manager that violates this section shall be subject to a penalty in an amount
not exceeding $5,000.� Each day the pharmacy benefits manager is in violation
shall constitute a separate violation.� The penalty may be recovered in a
summary proceeding by the Department of Banking and Insurance pursuant to the
"Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et
seq.).
���� The Department of Banking and
Insurance shall investigate and enforce violations of this section.� A local
unit employer may refer a violation of this section to the department.� The
department shall compel disclosure of claims experience data required to be
disclosed pursuant to subsection a. of this section if a violation is found.
���� c.���� For the purposes of
this section, "local unit" means any municipal government, county
government, board of education, fire or other special district that raises
or relies upon property tax revenue as a budget revenue, or joint meeting, or any
board, commission, or agency thereof.
���� 5.��� This act shall take
effect on the 180th day next following the date of enactment.
STATEMENT
���� This bill requires health care
claims experience data to be shared with local governments upon request under
certain circumstances.
���� The bill requires carriers and
third-party administrators that provide health care benefits to employees of local
units to provide complete claims experience data to local unit employers that
make a written request for their claims experience information, including loss
reports and large claims data.
���� The bill establishes identical
health care claims experience data sharing requirements for third-party medical
claims reviewers that contract with the State Health Benefits Program and
School Employees Health Benefits Program for local unit employers that
participate in those programs, with respect to those employers� employees.
���� The bill establishes prescription
drug claims experience data sharing requirements for pharmacy benefits managers
that provide prescription drug benefits to employees of a local unit.� Pharmacy
benefits managers are required to provide complete prescription claims
experience data to a local unit employer that makes a written request for its
claims experience information, including claim-level prescription data, rebate
amounts received by the pharmacy benefits manager, and a disclosure of spread
pricing practices.
���� All claims experience data
required to be shared under the bill is required to be provided in an
electronic and manual format within 60 days of the receipt of the request at no
cost to the employer.� The bill requires claims experience data to be issued in
a manner that complies with the privacy requirements of the federal �Health
Insurance Portability and Accountability Act of 1996.�
���� The bill provides that
carriers, third-party administrators, pharmacy benefits managers, and other
entities that violate the provisions of the bill are subject to a penalty in an
amount not exceeding $5,000.� Each day the entity is in violation constitutes a
separate violation.�
���� The bill provides that the
Department of Banking and Insurance may investigate and enforce violations of
its provisions.� A local unit employer may refer violations to the department.�
The department is required to compel disclosure of claims experience data
required to be disclosed pursuant to the bill upon a finding of violation.