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A 5217

Relates to dimensions and weights of vehicles

2025 Regular Session Introduced by Karl Brabenec

A5217 requires insurers and PBMs to count third‑party payments toward enrollees’ cost sharing, ending accumulator practices that ignore such assistance.

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Bill Summary · A 5217

Summary — A5217 (Ensuring Fairness in Cost‑Sharing Amounts Act of 2025)

Note: although the header provided with the request lists a vehicle‑related title, the bill text and committee materials for A5217 concern health insurance “accumulators” and third‑party payment crediting. This summary reflects the bill content in the legislative documents.

Purpose

A5217 prohibits insurers and pharmacy benefit managers (PBMs) from using so‑called “copay accumulator” practices. It requires carriers/PBMs to credit third‑party payments or discounts (for example, manufacturer coupons, charitable assistance, or other third‑party payments made on behalf of an enrollee) toward the enrollee’s copayments, coinsurance, deductibles, or other out‑of‑pocket cost‑sharing obligations under a health benefits plan.

Key provisions

  • Prohibition of accumulators: Carriers and PBMs must count any payment or discount paid by the enrollee or on the enrollee’s behalf toward the enrollee’s cost‑sharing liability (copay, coinsurance, deductible, etc.) for covered services, including prescription drugs.
  • High‑deductible/HSA plans: For plans that qualify as HSA‑eligible high‑deductible health plans, third‑party payments are applied to deductibles only to the extent permitted by federal tax law; the bill specifies application after the enrollee has satisfied the federal minimum deductible except for preventive services (which are credited regardless).
  • PBM and carrier conduct: Carriers and third‑party administrators may not design or condition plan terms or benefit design based on information about the availability or amount of third‑party financial/product assistance for a prescription drug.
  • Annual certification: Each carrier and third‑party administrator must annually certify compliance to the Commissioner of Banking and Insurance (reprint sets the deadline as March 31), with CEO/CFO or designee signature.
  • Rulemaking: The Department of Banking and Insurance is directed to adopt implementing regulations.
  • Preservation of regulatory authority: Committee amendments clarify the Department may impose additional cost‑sharing limits consistent with state law/regulations.

Plans excluded

The bill excludes several plans from its scope, e.g.: accident only; credit disability; long‑term care; Medicare supplemental; TRICARE supplemental; coverage for Medicare services/contracts with the federal government; State Medicaid (NJ FamilyCare); workers’ compensation; the State Health Benefits Program and School Employees’ Health Benefits Program; ERISA‑governed self‑insured plans; private passenger auto policies; and hospital confinement indemnity coverage.

Who is affected

  • Insured individuals (enrollees) — will have third‑party payments counted toward cost sharing.
  • Health insurance carriers and PBMs operating in New Jersey — required to change accrual/claims processes and certify compliance.
  • Employers and local governments offering privately‑marketed coverage — may see premium or cost changes.
  • Department of Banking and Insurance — rulemaking and oversight responsibilities.

Fiscal impact (Office of Legislative Services)

  • OLS estimates an indeterminate increase in local government costs (and earlier drafts flagged potential state and local impacts). Costs may rise because some enrollees will meet cost‑sharing limits sooner, shifting costs to insurers and potentially increasing premiums. Magnitude is unknown and depends on enrollee numbers and value of third‑party discounts.
  • OLS notes possible future savings if improved affordability increases adherence and reduces downstream treatment costs.
  • No expected impact on NJ FamilyCare due to federal prohibitions on manufacturer coupons for Medicare/Medicaid beneficiaries.

Legislative status & timeline

  • Introduced in Assembly: 1/23/2025 (Sponsor: Asm. Karl Brabenec).
  • Reported out of Assembly committees and passed Assembly 3/24/2025 (78–0–0).
  • Received in Senate 5/12/2025; referred to Senate Budget & Appropriations.
  • Reported by Senate committee with amendments 6/9/2025; Senate amendment recorded 6/30/2025.
  • Companion bill: S3818; prior‑session related bills listed (A6120, A5648, A5559, A5633, A5572).

Practical effect

If enacted, A5217 would end insurer and PBM practices that deny credit for third‑party assistance when calculating enrollee out‑of‑pocket progress, increasing transparency and reducing instances where enrollees exhaust financial assistance without it lowering their plan deductibles or out‑of‑pocket maximums. Carriers and PBMs would need to revise systems and certify compliance annually.

Compiled from official sources — confirm details with the bill’s official record.

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