25.0068.04000
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; 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.
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, copayment, or deductible under a health
benefit plan.
b."Enrollee" means an individual entitled to prescription drug coverage under a
health benefit plan.
c."Health benefit plan" has the same meaning as provided under section
26.1 - 36.3 - 01.
d."Prescription drug" means a drug for which a prescription is required:
(1)Without a generic equivalent; or
(2)With a generic equivalent, if 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.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
Page No. 1 25.0068.04000
HOUSE BILL NO. 1216
HOUSE BILL NO. 1216
with Senate Amendments
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22 Sixty-ninth
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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 person. The health benefit
plan may not vary the out - of - pocket maximum or cost - sharing requirement, or
otherwise design benefits accounting for the availability of a cost - sharing assistance
program for a prescription drug.
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.
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,
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.
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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.
SECTION 3. APPLICATION. This Act applies effective January 1, 2026, to the public
employees retirement system uniform group insurance program health insurance benefits
coverage, regardless of the health insurance benefits coverage contract issuance or renewal
date. This Act applies effective January 1, 2026, or upon the next renewal after January 1,
2026, to health benefit plans.
SECTION 4. EFFECTIVE DATE. This Act becomes effective on January 1, 2026.
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