25.0068.02000
Sixty-ninth
Legislative Assembly
of North Dakota
Introduced by
Representatives Karls, Hagert, Kiefert, Wagner
Senators Boschee, Dever, Sorvaag
A BILL for 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; and to amend and
reenact section 26.1-36.6-03 of the North Dakota Century Code, relating to self-insurance
health care plans.
BE IT ENACTED BY THE LEGISLATIVE ASSEMBLY OF NORTH DAKOTA:
SECTION 1. A new section to chapter 26.1-36 of the North Dakota Century Code is created
and enacted as follows:
Out - of - pocket expenses - Prescription drugs.
1.As used in this section:
a."Cost-sharing" means any coinsurance or copayment under a health benefit plan.
b."Enrollee" means an individual entitled to prescription drug coverage under a
health benefit plan.
c."Grandfathered health plan" has the meaning stated in the Patient Protection and
Affordable Care Act [Pub. L. 111-148], as amended by the Health Care and
Education Reconciliation Act of 2010 [Pub. L. 111-152]. The term includes the
public employees retirement system uniform group insurance program's
grandfathered preferred provider organization plan.
d."Health benefit plan" has the same meaning as provided under section
26.1 - 36.3 - 01.
e."Prescription drug" means a drug for which a prescription is required:
(1)Without a generic equivalent; or
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21 Sixty-ninth
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(2)With a generic equivalent and the enrollee has obtained access to the drug
through prior authorization, a step therapy protocol, or the heath care
insurer's expectations and appeals process.
2.a.Except as provided under subsection 4, to the extent permitted by federal law
and regulation, an insurer may not deliver, issue, execute, or renew a health
benefit plan providing prescription drug coverage unless when calculating an
enrollee's overall contribution to any out - of - pocket maximum or any cost - sharing
requirement for a prescription drug under the health benefit plan, the health
benefit plan provides for the inclusion of any amount paid by the enrollee or paid
on behalf of the enrollee by another individual.
b.The health benefit plan may not vary the out - of - pocket maximum or cost - sharing
requirement, or otherwise design benefits in a manner that takes into account the
availability of a cost - sharing assistance program for a prescription drug.
c.An amount paid by a cost - sharing assistance program for a prescription drug
may apply to an enrollee's copayment but may not apply to the annual deductible
or out-of-pocket maximum. An enrollee shall notify the insurer of any cost-sharing
assistance used to reduce a copayment.
3.If application of this section would result in ineligibility of a health benefit plan that is a
qualified high - deductible health plan to qualify as a health savings account under
section 223 of the Internal Revenue Code [26 U.S.C. 223], the requirements of this
section do not apply with respect to the deductible of the health benefit plan until after
the enrollee has satisfied the minimum deductible under section 26 U.S.C. 223.
4.This section does not apply to a grandfathered health plan.
SECTION 2. AMENDMENT. Section 26.1-36.6-03 of the North Dakota Century Code is
amended and reenacted as follows:
26.1-36.6-03. Self-insurance health plans - Requirements. (Effective through July 31,
2025)
1.The following policy provisions apply to a self-insurance health plan or to the
administrative services only or third-party administrator, and are subject to the
jurisdiction of the commissioner: sections 26.1-36-03, 26.1-36-03.1, 26.1-36-05,
26.1-36-10, 26.1-36-12, 26.1-36-12.4, 26.1-36-12.6, 26.1-36-13, 26.1-36-14,
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26.1-36-17, 26.1-36-18, 26.1-36-19, 26.1-36-23, 26.1-36-29, 26.1-36-37.1, 26.1-36-38,
26.1-36-39, 26.1-36-41, 26.1-36-44, and 26.1-36-46.
2.The following health benefit provisions applicable to a group accident and health
insurance policy under chapter 26.1-36 apply to a self-insurance health plan and are
subject to the jurisdiction of the commissioner: sections 26.1-36-06, 26.1-36-06.1,
26.1-36-07, 26.1-36-08, 26.1-36-08.1, 26.1-36-09, 26.1-36-09.1, 26.1-36-09.2,
26.1-36-09.3, 26.1-36-09.5, 26.1-36-09.6, 26.1-36-09.7, 26.1-36-09.8, 26.1-36-09.9,
26.1-36-09.10, 26.1-36-09.11, 26.1-36-09.12, 26.1-36-09.13, 26.1-36-09.14,
26.1-36-09.15, 26.1-36-11, 26.1-36-12.2, 26.1-36-20, 26.1-36-21, 26.1-36-22,
26.1-36-23.1, and 26.1-36-43. Section 54-52.1-04.18 applies to a self-insurance health
plan and is subject to the jurisdiction of the commissioner.
Self-insurance health plans - Requirements. (Effective after July 31, 2025)
1.The following policy provisions apply to a self-insurance health plan or to the
administrative services only or third-party administrator, and are subject to the
jurisdiction of the commissioner: sections 26.1-36-03, 26.1-36-03.1, 26.1-36-05,
26.1-36-10, 26.1-36-12, 26.1-36-12.4, 26.1-36-12.6, 26.1-36-13, 26.1-36-14,
26.1-36-17, 26.1-36-18, 26.1-36-19, 26.1-36-23, 26.1-36-29, 26.1-36-37.1, 26.1-36-38,
26.1-36-39, 26.1-36-41, 26.1-36-44, and 26.1-36-46.
2.The following health benefit provisions applicable to a group accident and health
insurance policy under chapter 26.1-36 apply to a self-insurance health plan and are
subject to the jurisdiction of the commissioner: sections 26.1-36-06, 26.1-36-06.1,
26.1-36-07, 26.1-36-08, 26.1-36-08.1, 26.1-36-09, 26.1-36-09.1, 26.1-36-09.2,
26.1-36-09.3, 26.1-36-09.5, 26.1-36-09.6, 26.1-36-09.7, 26.1-36-09.8, 26.1-36-09.9,
26.1-36-09.10, 26.1-36-09.11, 26.1-36-09.12, 26.1-36-09.13, 26.1-36-09.14,
26.1-36-09.15, 26.1-36-11, 26.1-36-12.2, 26.1-36-20, 26.1-36-21, 26.1-36-22,
26.1-36-23.1, and 26.1-36-43. Section 1 of this Act applies to a self-insurance health
plan and is subject to the jurisdiction of the commissioner.
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