AN ACT to create and enact a new section to chapter 26.1-36 of the North Dakota Century Code, relating to out-of-pocket expenses for prescription drugs; to amend and reenact section 26.1-36.6-03 of the North Dakota Century Code, relating to self-insurance health care plans; to provide for application; and to provide an effective date.
HB 1216 creates a new North Dakota insurance requirement governing how prescription drug cost-sharing assistance is treated in health benefit plans. For covered prescription drugs, insurers generally could not exclude amounts paid by an enrollee or on the enrollee’s behalf by another person from counting toward the plan’s out-of-pocket maximum or other cost-sharing limits. The bill also prohibits health plans from designing benefits to account for the availability of a prescription drug cost-sharing assistance program, subject to federal law and regulation.
The bill defines key terms such as cost-sharing, enrollee, health benefit plan, and prescription drug. It applies to drugs without a generic equivalent, and in some cases to drugs with a generic equivalent when access is obtained through prior authorization, step therapy, or the insurer’s exceptions and appeals process. It also includes a safeguard for qualified high-deductible health plans so the new rule does not interfere with health savings account eligibility until the federal minimum deductible is met.
HB 1216 also amends the state law governing self-insurance health plans, making the new prescription drug cost-sharing rule applicable to self-insured plans under the commissioner’s jurisdiction. The bill applies to the Public Employees Retirement System uniform group insurance program beginning January 1, 2026, and to other health benefit plans on January 1, 2026, or at the next renewal after that date. Overall, the bill expands state insurance regulation affecting insurers, self-funded employer plans, and public employee coverage.
The general sentiment appears supportive but not unanimous, with the bill passing both chambers by clear margins. The House and Senate votes show meaningful bipartisan approval, but also notable opposition, suggesting concern about cost, plan design, or regulatory burden. No committee transcript was provided, so the available record shows support in the final votes but does not identify detailed floor arguments.
The main point of contention is likely the requirement that insurers count third-party prescription assistance toward deductibles and out-of-pocket limits, which can affect how copay assistance programs are used and how plans manage drug costs. Opponents may have viewed the bill as interfering with benefit design or increasing premiums, while supporters likely saw it as improving affordability for patients facing high prescription drug costs. The high-deductible health plan carveout indicates an effort to address concerns about federal tax treatment and HSA compatibility.
HB 1216 adds a new insurance mandate to chapter 26.1-36 and extends it to self-insurance health plans through section 26.1-36.6-03. It changes how insurers and self-funded plans must calculate out-of-pocket maximums and cost-sharing for certain prescription drugs, requiring inclusion of amounts paid by the enrollee or on the enrollee’s behalf, and limiting plan designs that respond to copay assistance programs. The bill also affects the Public Employees Retirement System uniform group insurance program and applies prospectively beginning in 2026.
The bill’s voting history suggests generally favorable sentiment in both chambers, with passage by substantial but not overwhelming margins. That pattern indicates broad support for lowering prescription drug costs, alongside a significant minority concerned about the policy’s effects on insurance pricing, plan administration, or the use of manufacturer assistance programs. No committee discussion was available to show more specific debate.
The central contention is whether copay assistance and other third-party payments should count toward deductibles and out-of-pocket caps. Supporters likely argued the bill helps patients reach coverage limits faster and reduces prescription drug expenses, while opponents likely worried it could undermine insurer cost controls, raise premiums, or encourage higher drug prices. Another likely concern is the interaction with high-deductible health plans and federal HSA rules, which the bill addresses with a specific exception.