Requires DOBI to establish all-payer claims database.

S4501

SENATE, No. 4501

STATE OF NEW JERSEY

222nd LEGISLATURE

�

INTRODUCED JUNE 22, 2026

Sponsored by:

Senator� RAJ MUKHERJI

District 32 (Hudson)

SYNOPSIS

���� Requires DOBI to establish all-payer claims database.

CURRENT VERSION OF TEXT

���� As introduced.

��

An Act

establishing an all-payer claims database and
supplementing Title 17B of the New Jersey Statutes.

����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:

���� 1.��� As used in this act:

���� �All-payer claims database�
means a database that receives and stores data from a reporting entity
concerning health insurance claims, prescription drug claims, and other health
insurance claims information from covered persons.

���� �Carrier� means an insurance
company, health service corporation, hospital service corporation, medical
service corporation, or health maintenance organization authorized to issued
health benefits plans in this State, and shall include the State Health Benefits
Program, School Employees Program, and State Medicaid program established
pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

���� �Covered person� means a
person on whose behalf a carrier is obligated to pay benefits or provide
services pursuant to a health benefits plan.

���� �Department� means the
Department of Banking and Insurance.

���� �Health benefits plan� means a
benefits plan which pays hospital or medical expense benefits for covered
services, or prescription drug benefits for covered services, and is delivered
or issued for delivery in this State by or through a carrier or any other
sponsor.� For the purposes of this act, �health benefits plan� shall include,
to the maximum extent permitted by federal law, a high-deductible health plan,
except if the plan is used to establish a medical savings account pursuant to
section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220).�
�Health benefits plan� shall not include the following plans, policies or
contracts: accident only, credit disability, long-term care, Medicare
supplement coverage, TRICARE supplement coverage, coverage for Medicare
services pursuant to a contract with the United States government, coverage
arising out of a worker's compensation or similar law, coverage under a policy
of private passenger automobile insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1
et seq.), or hospital confinement indemnity coverage.�

���� �Health care provider� means a
physician or other health care professional licensed pursuant to Title 45 of
the Revised Statutes and a hospital or other health care facility licensed
pursuant to Title 26 of the Revised Statutes.

���� �Institutional review board�
means group regulated pursuant to 45 C.F.R. s.46 to review and monitor research
involving human subjects.

���� �Longitudinal identifier�
means a unique, persistent, and tokenized identifier used to link a covered
person�s health insurance claims, prescription drug claims, and other health
insurance claims information submitted to the all-payer claims database.

���� �Reporting entity" means
a carrier, health care provider, pharmacy benefits manager, and third-party
administrator.� �Reporting entity� shall not include self-insured health
benefits plans governed by the provisions of the federal "Employee Retirement
Income Security Act of 1974" (29 U.S.C. s.1001 et seq.).

���� �Third party administrator�
means a person or entity that processes health insurance claims and pays claims
on behalf of a carrier without assumption of financial risk.� �Third party
administrator� shall include: (1) an entity not licensed as a carrier that is
not a subsidiary or affiliate of a carrier, that process claims on behalf of
the carrier; (2) an entity that is a subsidiary or affiliate of a carrier that,
as part of its purpose, processes claims on behalf of the carrier; and (3) an
entity that is a subsidiary or affiliate of a carrier that only processes
claims on behalf of a carrier other than an insurance company, health service
corporation, hospital service corporation, medical service corporation, or
health maintenance organization.� �Third party administrator� shall not include
a pharmacy benefits manager, collection agency, or subsidiary or affiliate of a
carrier that is formed solely for the purpose of processing and paying claims
on behalf of the carrier.

���� 2.��� a. �The department shall
establish, in collaboration with the New Jersey Hospital Association, New
Jersey Medical Association, and other health care organizations in the State,
an all-payer claims database for the purpose of collecting, assessing, and
reporting data on:

���� (1)�� medical claims,
including laboratory testing and behavioral health claims;

���� (2)�� prescription drug
claims;

���� (3)�� dental and vision
claims;

���� (4)�� eligibility and
enrollment; and

���� (5)�� health care provider
information.�

���� b.��� Pursuant to subsection
a. of this section, the department shall:

���� (1)�� oversee the planning,
implementation, and administration of the all-payer claims database;

���� (2)�� ensure that data
received is securely collected, compiled, and stored in accordance with State
and federal law;

���� (3)�� conduct audits of data
submitted by reporting entities to verify accuracy;

���� (4)�� publish data reported
pursuant to subsection e. of this section on a public dashboard within the
Internet website of the department; and

���� (5)�� maintain written
procedures for the administration of the all-payer claims database.� Pursuant
to this paragraph, the written procedures shall include but not be limited to:

���� (a)�� reporting requirements
for reporting entities; and

���� (b)�� requirements for
providing notice to a reporting entity regarding any alleged failure on the
part of the reporting entity to comply with the reporting requirements pursuant
to subparagraph (a) of this paragraph.

���� c.���� The department shall
seek funding from the federal government and other public sources to cover the
costs associated with the planning, implementation, and administration of the
all-payer claims database.

���� d.��� (1)� The department
shall allow researchers and research institutions, after receiving a written
request from the researcher or research institution that is made in a form and
manner prescribed by the department, to access data collected through the all-payer
claims database established pursuant to subsection a. of this section, if:

���� (a)�� the researcher or
research institution has received approval to do specific research or
statistical work from an institutional review board;

���� (b)�� the request for data
access is for a specified period; and

���� (c)�� the researcher or
research institution agrees in writing to protect the confidentiality of the
data pursuant to State and federal law.

���� (2)�� The department shall
collect a fee for each researcher or research institution seeking access
pursuant to subparagraph (a) of this paragraph.� The fees collected pursuant to
this paragraph shall be used to cover the costs associated with the planning,
implementation, and administration of the all-payer claims database.

���� e.���� (1)� Upon adoption of
the reporting requirements established pursuant to subparagraph (a) of
paragraph (5) of subsection b. of this section, a reporting entity shall report
data for inclusion in the all-payer claims database in a form and manner
prescribed by the department. �Any data submitted by a reporting entity
pursuant to this paragraph may be viewed by that entity before the data is
published on the all-payer claims database to verify accuracy.

���� (2)�� A self-insured health
benefits plan governed by the provisions of the federal �Employee Retirement
Income Security Act of 1974� (29 U.S.C. s.1001 et seq.) may voluntarily report,
to the maximum extent that is permitted by federal law, data to the department
pursuant to paragraph (1) of this subsection.

���� f.���� (1) The department
shall utilize data in the all-payer claims database to provide covered persons
with information concerning the cost and quality of health care services for
the purpose of allowing covered persons to make economically sound and medically
appropriate health care decisions.�

���� (2)�� Any disclosures of the
data within the all-payer claims database made pursuant to paragraph (4) of
subsection b. of this section and paragraph (1) of subsection d. of this
section, and to potential covered persons pursuant to paragraph (1) of this
subsection, shall be made in a manner to protect the confidentiality of the
data pursuant to State and federal law. �Pursuant to this subsection,
disclosures of data shall also be made in a manner to protect the
confidentiality of health care providers.

���� (3)�� To effectuate the
provisions of paragraph (1) of this subsection, data submitted pursuant to that
paragraph shall include a unique longitudinal identifier for the use of each
covered person to track health care usage over time.

���� g.��� The department may enter
into a contract with a private entity or entities to plan, implement, or
administer the all-payer claims database.

���� 3.��� The department may,
after issuing notice and holding a hearing, impose a civil penalty on any
reporting entity that fails to report health insurance information as
prescribed pursuant to subsection e. of section 2 of this act, in an amount
that is not to exceed $1,000 per day that the violation continues.� All
penalties assessed under this section shall be payable to the department and
may be recovered with costs in a summary proceeding commenced by the
commissioner pursuant to the �Penalty Enforcement Law of 1999,� P.L.1999, c.274
(C.2A:58-10 et seq.).

���� 4.��� The department shall
promulgate rules and regulations, pursuant to the �Administrative Procedure
Act,� P.L.1968, c.410 (C.52:14B-1 et seq.) to effectuate the provisions of this
act.

���� 5.��� This act shall take
effect on the first day of the twelfth month next following enactment.

STATEMENT

���� This bill requires DOBI, in collaboration
with the New Jersey Hospital Association, New Jersey Medical Association, and
other health care organizations in the State, to establish an all-payer claims
database.

���� Under the bill, DOBI and its
collaborators will be required to oversee the planning, implementation, and
administration of an all-payer claims database for the purpose of collecting,
assessing, and reporting:

���� (1)�� medical claims,
including behavioral health claims;

���� (2)�� prescription drug
claims;

���� (3)�� dental and vision
claims;

���� (4)�� eligibility and
enrollment; and

���� (5)�� health care provider
information.�

���� The department will:

���� (1)�� ensure that data
received is securely collected, compiled, and stored in accordance with State
and federal law;

���� (2)�� conduct audits of data
submitted by reporting entities to verify accuracy;

���� (3)�� publish data reported
pursuant to the bill on a public dashboard within the Internet website of the
department; and

���� (4)�� maintain written
procedures for the administration of the all-payer claims database.�

���� The bill requires reporting
entities to report data for inclusion in the all-payer claims database in the
form and manner to be prescribed by the department.� The bill also requires the
department to utilize data in the all-payer claims database to provide covered
persons with information concerning the cost and quality of health care
services for the purpose of allowing covered persons to make economically sound
and medically appropriate health care decisions.� To achieve this, data
submitted to the all-payer claims database under this bill will include a
unique longitudinal identifier for the use of each covered person to track
health care usage over time.

���� Finally, the commissioner of
the department may, after notice and hearing, impose a penalty on any reporting
entity that fails to report health insurance information as prescribed pursuant
to the bill, not to exceed $1,000 per day that the violation continues.�

���� For the purposes of this bill:

���� �All-payer claims database�
means a database that receives and stores data from a reporting entity
concerning health insurance claims, prescription drug claims, and other health
insurance claims information from covered persons.�

���� �Reporting entity" means
a carrier, health care provider, pharmacy benefits manager, and third-party
administrator.� �Reporting entity� shall not include self-insured health
benefits plans governed by the provisions of the federal "Employee Retirement
Income Security Act of 1974" (29 U.S.C. s.1001 et seq.).