A5540

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: