Bill
HB 1216
HB 1216 requires health plans to count third-party prescription drug payments toward enrollees' out-of-pocket maximums and bans plan designs that exclude copay assistance.
Status (as of documents provided)
- Introduced Nov 12, 2024; filed with Secretary of State 04/29 (documents include multiple amendment versions).
- A version with Senate amendments sets an effective date of January 1, 2026 and applies to certain public employee group coverage regardless of contract renewal date. Several committee amendments were considered during 2025.
Purpose and intent
- To require health benefit plans (including many self‑insured plans subject to state jurisdiction) to count amounts paid for prescription drugs — including third‑party cost‑sharing assistance paid on behalf of an enrollee — toward an enrollee’s out‑of‑pocket maximum and to prohibit plan design that treats copay assistance differently from enrollee cost‑sharing, to the extent allowed by federal law.
Key definitions (from the bill)
- Cost‑sharing: coinsurance, copayment, deductible under a health benefit plan.
- Enrollee: an individual entitled to prescription drug coverage.
- Health benefit plan: as defined in NDCC § 26.1‑36.3‑01.
- Prescription drug: either (a) a drug for which a prescription is required and has no generic equivalent, or (b) a drug with a generic equivalent for which the enrollee obtained access only after prior authorization, step therapy, or insurer appeal/exception processes.
Main provisions
- Insurers may not issue, deliver, execute, or renew a health benefit plan that, when calculating an enrollee’s contribution to an out‑of‑pocket maximum or other prescription‑drug cost‑sharing requirement, excludes amounts paid by the enrollee or by another person on the enrollee’s behalf (e.g., manufacturer copay assistance), to the extent permitted by federal law and regulation.
- Health plans may not vary out‑of‑pocket maximums or cost‑sharing requirements, or otherwise design benefits, to take into account the availability of cost‑sharing assistance programs for prescription drugs.
- Special rule for high‑deductible health plans (HSA‑qualified): if applying these rules would make a plan ineligible as an HSA‑qualified plan under IRC §223, the rule does not apply to the deductible until the enrollee has satisfied the minimum deductible required for HSA eligibility.
- Amends NDCC § 26.1‑36.6‑03 to extend the commissioner’s jurisdiction over self‑insurance plans and explicitly subject self‑insured plans to the new prescription drug out‑of‑pocket provisions (effective after July 31, 2025 in some versions).
- Application language in amendments: the law applies to health benefit plans delivered/issued/renewed after the effective date, with some versions specifying January 1, 2026 and earlier application to the public employees retirement system uniform group insurance program regardless of contract date.
Who is affected
- Primary: health insurers issuing regulated group and individual plans in North Dakota and self‑insured plans and third‑party administrators that fall under the commissioner’s jurisdiction.
- Secondary: enrollees who use prescription drugs and/or use cost‑sharing assistance (e.g., manufacturer copay assistance, charitable assistance) — these payments would count toward out‑of‑pocket limits under the bill.
- Employers sponsoring self‑insured plans will face new compliance and plan‑design requirements if their plans are subject to state oversight.
Procedural/timing notes and legal considerations
- The bill repeatedly qualifies obligations “to the extent permitted by federal law and regulation,” reflecting potential preemption or limits imposed by federal rules governing HSAs and ERISA‑governed self‑funded employer plans.
- Committee reports and alternate amendment texts show differing treatments (for example, a committee version excluded “grandfathered” plans; another clarified limits on applying assistance to deductibles vs. copayments). Final application and scope depend on the exact enrolled/amended text and effective date adopted.
- Implementation actions likely required: plan form and system updates, communication to enrollees, regulatory guidance from the Insurance Commissioner; employers with ERISA plans may need to determine preemption issues.
Bottom line
HB 1216 seeks to make third‑party payments for prescription drugs count toward enrollees’ cost‑sharing limits and to prohibit plan designs that circumvent copay assistance — expanding protection for consumers who rely on assistance programs while raising questions about interactions with federal HSA rules and ERISA‑governed self‑insured plans.
Compiled from official sources — confirm details with the bill’s official record.
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