AB714: Bill Text

2025 - 2026 LEGISLATURE

LRB-5095/1

EKL:emw

2025 ASSEMBLY BILL 714

December 3, 2025 - Introduced by Representatives Wittke, O'Connor, Steffen, Kreibich, Murphy, Duchow, Piwowarczyk, Knodl, Moses and Doyle, cosponsored by Senator Hutton. Referred to Committee on Insurance.

AB714,1,3 An Act to create 633.01 (2w), 633.01 (3m), 633.01 (4m), 633.01 (4n), 633.04 (12) and 633.065 of the statutes; relating to: plan sponsors’ right to access claims data.

Analysis by the Legislative Reference Bureau

This bill imposes requirements on employee benefit plan administrators, insurers for large group health benefit plans, and pharmacy benefit managers regarding the ability of a plan sponsor (for example, an employer) to access claims data and other information. The bill requires that a contract between an administrator, insurer, or pharmacy benefit manager and a plan sponsor to provide services must specify that the plan sponsor owns the claims data relating to the contract. The bill also provides that claims data may not be sold to any party without the permission of the plan sponsor and the individual to whom the claims data relates.

Under the bill, an administrator, insurer, or pharmacy benefit manager must provide certain information to the plan sponsor or the plan sponsor’s designee within seven business days upon request. An administrator or insurer must provide claims data and payments, the amounts of fees and discounts, and, if requested, itemized billing statements and medical records associated with a specific claim. A pharmacy benefit manager must provide prescription drug claims and payments, rebate amounts provided by pharmaceutical manufacturers, and the amounts of revenue and fees derived from the contract. The bill allows the plan sponsor or designee to request information three times per plan year, and each request may be for up to 24 months of data.

The bill prohibits an administrator, insurer, or pharmacy benefit manager from imposing a fee for requesting the information that exceeds the expenses reasonably incurred to provide the information and any condition restricting the plan sponsor’s or designee’s right to access the information.

Also under the bill, an administrator or insurer must provide, within seven business days of a written request, information about a claim exceeding or expecting to exceed $25,000, which is reduced to $10,000 for a pharmacy claim. The bill further requires that a pharmacy benefit manager provide, within seven business days of a written request, data regarding the amounts paid to a pharmacy or pharmacist on behalf of the plan sponsor.

Finally, the bill provides that the claims data and other information may not be modified or withheld from a plan sponsor or the plan sponsor’s privacy officer or other designee if the plan sponsor, privacy officer, or designee attests that the information will be used and disclosed only as permitted or required under federal laws and regulation.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB714,1 Section 1. 633.01 (2w) of the statutes is created to read:

AB714,2,5 633.01 (2w) “High-cost claim” means a claim that is associated with an individual who is provided health care coverage by a plan sponsor and in which the aggregate for an episode of care exceeds, or is expected to exceed within a 12-month period, any of the following:

AB714,2,6 (a) For a claim that is not a pharmacy claim, $25,000.

AB714,2,7 (b) For a claim that is a pharmacy claim, $10,000.

AB714,2 Section 2. 633.01 (3m) of the statutes is created to read:

AB714,2,11 633.01 (3m) “Large group health benefit plan” means a group health benefit plan, as defined in s. 632.745 (9), if the group consists of at least 50 employees or includes at least 50 eligible employees, as defined in s. 632.745 (5).

AB714,3 Section 3. 633.01 (4m) of the statutes is created to read:

AB714,2,13 633.01 (4m) “Plan sponsor” has the meaning given in s. 632.745 (22).

AB714,4 Section 4. 633.01 (4n) of the statutes is created to read:

AB714,3,3 633.01 (4n) “Plan sponsor’s designee” includes a business associate, as defined in 45 CFR 160.103.

AB714,5 Section 5. 633.04 (12) of the statutes is created to read:

AB714,3,6 633.04 (12) That the plan sponsor has ownership of and access to claims data as provided in s. 633.065.

AB714,6 Section 6. 633.065 of the statutes is created to read:

AB714,3,15 633.065 Plan sponsor ownership of and access to claims data. (1) Ownership of claims data. A contract between an administrator and a plan sponsor relating to health benefit coverage, between an insurer and a plan sponsor to provide coverage under a large group health benefit plan, or between a pharmacy benefit manager and a plan sponsor to administer or manage prescription drug benefits shall provide that the plan sponsor owns the claims data relating to the contract. Claims data may not be sold to any party without the permission of the plan sponsor and the individual to whom the claims data relates.

AB714,3,18 (2) Duties of administrator and insurers. A contract under sub. (1) between a plan sponsor and an administrator or insurer shall require the administrator or insurer to do all of the following:

AB714,3,22 (a) Provide the plan sponsor or plan sponsor’s designee, within 7 business days of a written request and in a form and manner that is acceptable to the plan sponsor or plan sponsor’s designee, the itemized billing statements and medical records associated with a high-cost claim prior to payment of the high-cost claim.

AB714,4,3 (b) Provide the plan sponsor or plan sponsor’s designee, within 7 business days of a written request and in a form and manner that is acceptable to the plan sponsor or plan sponsor’s designee, information on claims paid under the contract. The information shall include all of the following for the period specified by the plan sponsor or plan sponsor’s designee under sub. (4):

AB714,4,4 1. Claims data showing all of the following:

AB714,4,5 a. The effective date of coverage.

AB714,4,6 b. The total number of covered individuals.

AB714,4,7 c. The total monthly earned premium.

AB714,4,9 d. The total monthly dollar value of paid claims, regardless of the period in which the claims were incurred.

AB714,4,12 e. The beginning and ending date of the period for which claims were paid and the percentage of claims that were paid in less than 30 days, within 30 to 60 days, within 61 to 90 days, and after 90 days.

AB714,4,14 f. The reserve value as of the beginning of the period and the reserve value as of the date through which the paid claims data was obtained.

AB714,4,18 g. A description of each high-cost claim, including the diagnosis, prognosis, identifiable data about the individual to enable the identification of other insurance arrangements, dollar amount, status as open or closed, and total number of days in open status.

AB714,4,21 2. Claims, including electronic claims transactions, related to the contract that are received on any current standardized claim form approved by the federal government.

AB714,5,2 3. The claims payments, electronic funds transfers, and remittance advice notices related to the contract, including the paid premium and paid claims transactions over the same time period for professional and institutional services. The administrator or insurer shall provide the information under this subdivision as electronic files.

AB714,5,6 4. Fees charged to the plan sponsor for plan administration, claims processing, and any other service. The information provided under this subdivision shall include all amounts retained by the administrator or insurer in excess of the amounts paid for health claims and the basis and terms for the fees and retainage.

AB714,5,10 5. Any out-of-network fee or negotiated discount, aligned incentive program fee, pay-for-performance payment or recovery, cost-containment program fee, overpayment recovery program fee, subrogation fee, or other special program fee or discount related to the contract.

AB714,5,13 6. Any direct or indirect compensation paid to brokers, consultants, agents, agencies, or any other party in relation to the plan and the basis and terms for the compensation.

AB714,5,15 7. The itemized billing statements and medical records associated with a specific claim if requested.

AB714,5,17 8. Any other claims data requested by the plan sponsor or the plan sponsor’s designee.

AB714,5,20 (3) Duties of pharmacy benefit manager. A contract under sub. (1) between a plan sponsor and pharmacy benefit manager shall require the pharmacy benefit manager to do all of the following:

AB714,6,2 (a) Provide the plan sponsor or plan sponsor’s designee, within 7 business days of receipt of a written request and in a form and manner that is usable to the plan sponsor or designee, data regarding the amounts paid, directly or indirectly, for prescription drugs and pharmacy services by the pharmacy benefit manager to a pharmacy or pharmacist under the contract.

AB714,6,6 (b) Provide the plan sponsor or plan sponsor’s designee, within 7 business days of receipt of a written request and in a form and manner that is useable to the plan sponsor or plan sponsor’s designee, all of the following for the period specified by the plan sponsor or plan sponsor’s designee under sub. (4):

AB714,6,10 1. The prescription drug rebate amounts, identified by drug and therapeutic category, that are provided by a pharmaceutical manufacturer and generated by claims processed through the plan maintained by the plan sponsor. This subdivision applies to product-specific rebates and to general rebates.

AB714,6,13 2. The prescription drug claims, including electronic claims transactions, related to the contract that are received by the pharmacy benefit manager on any standardized claim form approved by the federal government.

AB714,6,16 3. The prescription drug claims payments, electronic funds transfers, and remittance advice notices related to the contract. The pharmacy benefit manager shall provide the information under this subdivision as electronic files.

AB714,6,22 4. The revenue and fees derived by the pharmacy benefit manager from the contract, including all direct and indirect remuneration from pharmaceutical manufacturers. If requested by the plan sponsor, the pharmacy benefit manger shall also specify all amounts retained by the pharmacy benefit manager in excess of the amounts paid out in pharmacy claims and the basis and terms for the revenue, fees, and retainage.

AB714,7,2 5. Any direct or indirect compensation paid to brokers, consultants, agents, agencies, or any other party in relation to the pharmacy benefit arrangement and the basis and terms for the compensation.

AB714,7,8 (4) Period covered by request. When making a request for information under sub. (2) (b) or (3) (b), a plan sponsor or plan sponsor’s designee shall specify the period of months for which the requested information is to be provided by the administrator, insurer, or pharmacy benefit manager. A contract under sub. (1) shall provide a plan sponsor or plan sponsor’s designee with the right to receive the information under sub. (2) (b) or (3) (b) for each of the following periods:

AB714,7,11 1. The 6-month period beginning on the first day of the plan year and, if requested by the plan sponsor or plan sponsor’s designee, the 18-month period ending on the day before the first day of the plan year.