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S 3818

Relates to the termination of law enforcement officer benefits for malfeasance or serious misconduct

2025 Regular Session Introduced by Luis Sepúlveda

Prohibits insurers and PBMs from copay accumulator programs that ignore third-party payments; credits such payments toward deductibles and out-of-pocket costs.

REFERRED TO CIVIL SERVICE AND PENSIONS
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Bill Summary · S 3818

Summary — S-3818 (Ensuring Fairness in Cost-Sharing Amounts Act)

Note on title: the document text and enacted captions indicate S-3818 addresses health insurance “accumulators” (copay/cost-sharing assistance). The bill is also captioned the “Ensuring Fairness in Cost-Sharing Amounts Act of 2024/2025.” (The title shown in the prompt about termination of law enforcement benefits appears to be an error or unrelated.)

Purpose / Intent

S-3818 prohibits insurers and pharmacy benefits managers (PBMs) from using “copay accumulator” programs that prevent third‑party payments or manufacturer coupons from counting toward an enrollee’s deductible/out‑of‑pocket maximum. The bill is intended to ensure third‑party discounts or payments are credited when calculating an enrollee’s liability for cost‑sharing.

Key provisions

  • Prohibits use of accumulators: carriers and third‑party administrators (TPAs) or PBMs must give credit toward an enrollee’s copayment, coinsurance, deductible, or other out‑of‑pocket cost for any amount (or portion) paid by the enrollee or on the enrollee’s behalf by a third party.
  • Applies federal ACA out‑of‑pocket annual limit (42 U.S.C. §1302) to all covered health care services under in‑state health benefits plans.
  • High‑deductible health plans (HDHPs) tied to Health Savings Accounts (HSAs): third‑party payments count toward deductible to the maximum extent permitted under federal law; if application would render HSA ineligible under IRC §223, crediting applies only after the minimum statutory deductible is met, except that preventive services are credited regardless.
  • Prohibits carriers/TPAs from setting or conditioning plan benefit design based on availability/amount of financial or product assistance for a prescription drug.
  • Annual compliance certification: each carrier and TPA must certify to the Commissioner of Banking and Insurance (form/manner set by commissioner) that it complied with the section for the prior year — deadline amended to March 31 each year.
  • Department of Banking and Insurance to adopt implementing rules.

The bill also modifies New Jersey’s PBM statute to broaden PBM practice scope and amend the definition of “cost‑sharing amount” to mirror the broader cost‑sharing definition.

Exclusions / Not covered

The law excludes certain plan types from its coverage, including (among others): accident‑only; credit disability; long‑term care; Medicare supplemental; TRICARE supplemental; federal Medicare services; Medicaid (NJ FamilyCare); workers’ compensation; State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP); and ERISA‑governed self‑insured employer plans. (Committee amendments clarify exclusions.)

Who is affected

  • Directly: health insurance carriers, PBMs, third‑party administrators, and enrollees whose plans are subject to State regulation.
  • Indirectly: employers (including local governments and school districts) purchasing private market coverage, and the Department of Banking and Insurance (administration/oversight).

Fiscal impact / policy effects

  • Office of Legislative Services (OLS) finds an indeterminate potential increase in annual costs: some enrollees may meet cost‑sharing requirements sooner, shifting costs to insurers and upward pressure on premiums. The magnitude is not estimated.
  • Potential for longer‑term cost offsets if improved medication adherence or health outcomes reduce future treatment costs.
  • Department of Banking and Insurance may incur administrative costs for oversight and rulemaking.

Legislative status / timeline (selected)

  • Introduced: Oct 24, 2024 (Senate Commerce Committee referral).
  • Reported by Senate Commerce Committee: Dec 12, 2024.
  • Referred to Senate Budget & Appropriations Committee: Dec 12, 2024.
  • Reported with committee amendments by Senate Budget & Appropriations: June 9, 2025 (amendments clarified exclusions from prohibition).
  • Senate amendment (Ruiz) adopted: June 30, 2025.
  • Recorded as REFERRED TO CIVIL SERVICE AND PENSIONS (Jan 30, 2025) in legislative actions log (procedural entries have occurred across committees).
  • Companion/identical bill: A-5217; related prior-session bills: S-2781, S-1920, S-8583; companion A-3408.

Practical effect

If enacted, insurers and PBMs doing business in New Jersey would be barred from using accumulator adjustments that ignore third‑party assistance when calculating enrollees’ cost‑sharing progress, subject to federal restrictions for HSA/HDHP plans and specified statutory exclusions.

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

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