Requires certain information to be included in SHBP and SEHBP claims experience data provided to certain public employers.

S3586

SENATE, No. 3586

STATE OF NEW JERSEY

222nd LEGISLATURE

�

INTRODUCED FEBRUARY 19, 2026

Sponsored by:

Senator� JAMES BEACH

District 6 (Burlington and Camden)

Senator� LINDA R. GREENSTEIN

District 14 (Mercer and Middlesex)

SYNOPSIS

���� Requires certain information to be included in SHBP
and SEHBP claims experience data provided to certain public employers.

CURRENT VERSION OF TEXT

���� As introduced.

��

An Act

concerning State Health Benefits Program and
School Employees� 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
and the School Employees� 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
or the School Employees� 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
and the School
Employees� 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
and the School Employees� 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 requires certain
information to be included in the State Health Benefits Program (SHBP) and the
School Employees� Health Benefits Program (SEHBP) claims experience data to be
provided to certain public employers.�

���� Under current law, the 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 that public employer to request and receive
the claims experience data if the public employer requested the data. Under the
bill, the same requirements would apply to the SEHBP.

���� This bill requires certain
information to be included in the claims experience data for SHBP and SEHBP.
The information specified in the bill 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 SHBP
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 (HIPAA) and related regulations. The bill further 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.
Under the bill, the same requirements would apply to the SEHBP.