Requires third-party discounts and payments for individuals covered by health benefits plans to apply to copayments, coinsurance, deductibles, or other out-of-pocket costs for covered benefits.
What changed between versions
The entire Section 4, which amended P.L.2015 c.179 (C.17B:27F-1) to add definitions for pharmacy benefits management terms (anticipated loss ratio, average wholesale price, brand-name drug, etc.), was struck from the bill.
A new Section 5(f) adds standalone definitions for cost-sharing amount, health benefits plan (with a list of excluded plan types including Medicaid, workers compensation, self-insured ERISA plans, and others), health care service, pharmacy benefits manager, and pharmacy benefits management services with detailed subcategories.
The annual compliance certification deadline for both carriers and pharmacy benefits managers was changed from December 31 to March 31 of each year.
The effective date changed from a fixed date of January 1, 2025 to the 90th day following enactment, and now explicitly applies only to plans, policies, and contracts delivered, issued, executed, or renewed on or after that date.
Language in both Section 3(e) and Section 5(e) stating that the State shall only regulate carriers/PBMs to the extent permissible under applicable law was removed, removing a federal preemption limitation on state regulatory authority.
Both Section 3(a) and Section 5(a) now include language clarifying that nothing limits the Department of Banking and Insurance's authority to impose additional cost-sharing limits consistent with State law, including minimum standards under N.J.A.C.11:22-5.1 et seq.
The act's short name was updated from 'Ensuring Fairness in Cost-Sharing Amounts Act of 2024' to 'Ensuring Fairness in Cost-Sharing Amounts Act of 2025.'
