Bill Text: NJ A2281 | 2024-2025 | Regular Session | Introduced
Bill Title: Requires certain information to be included in SHBP claims experience data provided to certain public employers.
Spectrum: Moderate Partisan Bill (Democrat 5-1)
Status: (Introduced) 2024-01-09 - Introduced, Referred to Assembly State and Local Government Committee [A2281 Detail]
Download: New_Jersey-2024-A2281-Introduced.html
STATE OF NEW JERSEY
221st LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2024 SESSION
Sponsored by:
Assemblywoman YVONNE LOPEZ
District 19 (Middlesex)
Assemblyman ANTHONY S. VERRELLI
District 15 (Hunterdon and Mercer)
Assemblyman LOUIS D. GREENWALD
District 6 (Burlington and Camden)
Co-Sponsored by:
Assemblywoman Flynn, Assemblymen Sampson, DeAngelo and Assemblywoman Murphy
SYNOPSIS
Requires certain information to be included in SHBP claims experience data provided to certain public employers.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel.
An Act concerning State Health Benefits Program claims experience data provided to certain public employers and amending P.L.2013, c.189.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L.2013, c.189 (C.52:14-17.37a) is amended to read as follows:
1. a. The State Health Benefits Program shall provide at no cost to the requestor, and not more than once [in a 24-month period] in each calendar year, complete claims experience data to a public employer other than the State that participates in the State Health Benefits Program and makes a written request for its claims experience information, including loss reports and large claims data. The State Health Benefits 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. When requested by a public employer other than the State, the data shall be made available, upon request, to the majority representatives of the employees of that public employer within 15 days of the receipt of the written request made by the majority representative.
Notwithstanding the above, the State Health Benefits 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.
Notwithstanding any provision of this section, no information shall be released in such form as to result in the identification of an individual or in such form as to adversely affect personal privacy rights.
b. At a minimum, the claims experience data shall include:
(1) Medical loss ratio reports;
(2) Group structure census report, including age, gender and member identification number or unique patient identifier;
(3) Medical claims summary report by classification;
(4) Medical high-level detailed claims report by classification, including member identification number or unique patient identifier, large medical claim data for anyone with claims in excess of $50,000 indicating if an employee or dependent, patient age and gender, diagnosis and prognosis, and all case management notes or information;
(5) Medical executive health summary;
(6) Top 20 diagnoses by amount paid;
(7) Top 20 diagnosis codes ranked by health care facility or institution and by amount paid;
(8) Top 20 diagnosis codes ranked by medical professional and by amount paid;
(9) Utilization by major disease category;
(10) Utilization by place of service with type of service;
(11) Aggregate specific report;
(12) Provider report with tax identification numbers;
(13) Network utilization report;
(14) Prescription claims report, including:
a. Member identification number or unique patient identifier ;
b. National drug code of the drug or medicine dispensed;
c. The number of days' supply dispensed;
d. Metric decimal quantity dispensed;
e. Final ingredient cost on the claim excluding sales tax and dispensing fee;
f. Dispensing fees added to the ingredient cost prior to member copayment;
g. Amount paid by patient for claims which includes copay and deductible;
h. Date prescription was filled at the pharmacy;
i. Type of pharmacy where the prescription was filled, whether retail, mail, long term care, Veterans Administration, or specialty pharmacy;
j. If the prescription was for a compound product; and
k. If the prescription was formulary or non- formulary;
(15) Prescription loss ratio reports;
(16) Top 50 drugs or medicines that require a doctor's prescription by total number dispensed;
(17) Top 50 drugs or medicines that require a doctor's prescription by total dollars paid;
(18) Number and type of ongoing maintenance prescriptions separately by mail order and by retail;
(19) Prescription claims experience;
(20) Prescription utilization summary;
(21) Prescription executive summary report;
(22) Prescription trend performance summary for each plan design;
(23) Prescription key performance indicator report;
(24) Prescription utilizer summary by cost;
(25) Prescription utilization summary by population; and
(26) Prescription quarterly rebate report.
(cf: P.L.2013, c.189, s.1)
2. This act shall take effect
on the 90th day after the date of enactment.
STATEMENT
This bill can be known and may be referred to as the Public Health Transparency Act.
Under current law, the State Health Benefits Program (SHBP) provides upon request 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 SHBP.
This bill changes the 24-month period to not more than once per calendar year, and adds language to allow the majority representative of the employees of public employer to be able to request and receive the claims experience data if a public employer requested the data.
This bill requires information to be included in the claims experience data. The information includes, but is not limited to, medical claims summary report by classification; top 50 drugs or medicines that require a doctor's prescription by total number dispensed; top 50 drugs or medicines that require a doctor's prescription by total dollars paid; number and type of ongoing maintenance prescriptions by mail order and retail; prescription utilization summary; prescription executive summary report; prescription trend performance summary for each plan design; and a prescription key performance indicator report.
Current law requires the State Health Benefits Program to 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, HIPPA, and related regulations. In addition, the bill specifies that no information will be released in such form as to result in the identification of an individual or in such form as to adversely affect personal privacy rights.
