North DakotaDrug plans count assistance toward patients' out-of-pocket limits
Starting in 2026, health plans count certain payments made for enrollees toward prescription drug costs, including for people in the public employees' insurance program.
What it does
Plans count payments made by or for an enrollee toward prescription drug copays, coinsurance, deductibles, and out-of-pocket limits. Federal rules and a special deductible rule for some high-deductible plans limit how this works.
The prescription drug payment rule also covers self-insurance health plans, which the insurance commissioner oversees under the law.
Argument forPeople using drug assistance may reach their plan's out-of-pocket limit sooner because payments made for them count toward it.
Argument againstPlans may have less room to shape drug benefits around assistance programs, which could limit how they manage costs for covered prescriptions.
More detail
Plans count amounts paid by or for an enrollee toward prescription drug cost-sharing and out-of-pocket limits. The rule covers people with prescription drug coverage. For a drug with a generic equivalent, it applies only if the person gained access through prior approval, step therapy, or the insurer's expectations and appeals process. This rule applies only to the extent federal law and regulations allow. Plans may not set limits or design benefits based on whether drug assistance is available. For a qualified high-deductible plan, the rule does not apply to its deductible until the enrollee meets the federal minimum deductible if applying it sooner would make the plan ineligible for health savings accounts. For health benefit plans, the law applies starting January 1, 2026, or at the plan's next renewal after that date.
The prescription drug payment rule applies to self-insurance health plans and is overseen by the insurance commissioner. This includes self-insurance coverage in the state public employees' uniform group insurance program. For the public employees' group insurance program, the law applies starting January 1, 2026, regardless of when the coverage contract was issued or renewed.
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Where it stands
- Introduced
- Passed House
- Passed Senate
- To Governor
- Became Law
Looking ahead
No hearings or votes scheduled.
History
- 2025
- May 2Filed with Secretary Of State 04/29Latest
- May 1Signed by Governor Kelly Armstrong 04/29Became Law
- Apr 28Sent to GovernorTo Governor
- Apr 28Signed by Speaker
- Apr 28Signed by President
- Apr 24Second reading, passed, yeas 56 nays 37Major
- Vote recorded Motion for Final Passage on HB 1216. Result: pass.Lower
- Apr 24Concurred
- Apr 21Returned to House (12)
- Vote recorded Motion for Final Passage on HB 1216. Result: pass.Upper
- Apr 21Second reading, passed as amended, yeas 29 nays 18Major
- Apr 21Amendment adopted, placed on calendar
- Apr 18Reported back amended, do not pass, placed on calendar 10 6 0Minor
- Apr 16Rereferred to Appropriations
- Apr 15Reported back amended, do pass, amendment placed on calendar 11 3 2Minor
- Mar 24Rereferred to Appropriations
- Vote recorded Motion for Final Passage on HB 1216. Result: pass.Upper
- Mar 24Reconsidered
- Mar 24Second reading, passed as amended, yeas 30 nays 14Passed Senate
- Mar 21Amendment adopted, placed on calendar
- Mar 20Reported back amended, do not pass, placed on calendar 4 1 1Minor
- Mar 10Committee Hearing 11:00
- Feb 20Introduced, first reading, referred Human Services CommitteeMinor
- Feb 20Received from House
- Feb 19Second reading, passed, yeas 69 nays 24Passed House
- Vote recorded Motion for Final Passage on HB 1216. Result: pass.Lower
- Feb 19Amendment failed, placed on calendarMinor
- Feb 18Reported back amended, do pass, amendment placed on calendar 12 1 1Minor
- Jan 27Committee Hearing 02:00
- Jan 21Committee Hearing 03:00
- Jan 10Introduced, first reading, referred Industry, Business and Labor CommitteeIntroduced
Healthcare