Bill Text: NJ A5046 | 2026-2027 | Regular Session | Introduced
Bill Title: Requires health care claims experience data to be shared with local governments.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced) 2026-05-11 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A5046 Detail]
Download: New_Jersey-2026-A5046-Introduced.html
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.
