North Dakota health insurance marketplace guide 2023

North Dakota did not establish its own exchange, so enrollments are completed via HealthCare.gov or an approved enhanced direct enrollment entity.

The North Dakota House of Representative voted against a state-run health insurance exchange in 2011, and then-Gov. Jack Dalrymple’s administration reiterated that position in November 2012.

But North Dakota expanded its Medicaid program under a provision of the Affordable Care Act. Dalrymple favored the expansion, and the state House approved the measure in February 2012. Enrollment in Medicaid in North Dakota increased by 72% percent from the end of 2013 to early 2022. Much of that growth has been the result of the COVID pandemic, and the Families First Coronavirus Response Act that prohibits Medicaid eligibility redeterminations during the COVID public health emergency.

For 2023 coverage, there are three insurers that offer exchange plans in North Dakota:

• Blue Cross Blue Shield of North Dakota (Noridian)
• Medica
• Sanford

In most counties, plans are available from all three insurers for 2023, although there are six counties where only two insurers offer plans (this was also the case in 2021, although all three insurers had statewide coverage areas in 2022).

North Dakota’s exchange has had more consistent insurer participation over the years than most states. Medica, Sanford, and Blue Cross Blue Shield of North Dakota (Noridian) all offered plans in 2014 — the first year the exchanges were operational — and continued to do so through 2017.

The first major change came in 2018 when Medica exited the exchange altogether. And although Sanford had offered plans statewide in previous years, they drastically reduced their coverage area in 2018. Sanford plans were only available in a total of five counties in the Fargo and Bismark areas. Residents in the rest of the state only had Blue Cross Blue Shield of North Dakota options available.

But for 2019, insurer participation returned to what it had been in 2017, with Sanford once again offering plans statewide, and Medica offering plans in all but a few northwestern counties. Blue Cross Blue Shield of North Dakota continues to offer plans statewide in the exchange, as they have since 2014.

And as of 2022, all three of the participating insurers offer plans statewide.

The open enrollment period for individual/family coverage (both on-exchange and off-exchange) runs from November 1 to January 15. Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.

Our comprehensive guide to open enrollment explains everything you need to know about open enrollment. And we also have a comprehensive guide to special enrollment periods, clarifying your options for enrollment outside of the annual open enrollment period. 

The North Dakota Insurance Department announced the following approved average rate changes in October 2022, for individual/family coverage effective in 2023:

• Medica: 8.51% increase. (a little lower than Medica proposed)
• Blue Cross Blue Shield of North Dakota/Noridian: 3.3% increase. (a little lower than BCBSND had proposed)
• Sanford: 5.67% increase. (approved without adjustments)

Across all three insurers, that amounts to an overall weighted average rate increase of 4.4% for 2023, before any subsidies are applied. Most enrollees receive subsidies, and their net premium changes depend on how subsidies change as well as how the rates for their plan change and whether they pick a different plan for 2023.

The American Rescue Plan, enacted in March 2021, increased the size of premium subsidies and made the subsidies more widely available. Fortunately for exchange enrollees, those subsidy enhancements have been extended through 2025 by the Inflation Reduction Act. 

Here’s a look at how average rates have changed over the years in North Dakota’s exchange:

• 2015: Average decrease of 3%. 2014 was the first year that ACA-compliant plans were available, and the rates were essentially actuaries’ educated guesses. PricewaterhouseCooper LLC calculated weighted average rate changes from 2014 to 2015 across the entire individual market (on and off-exchange), and found an average price decrease of 3% in North Dakota. But a Commonwealth Fund analysis in December 2014 found an average rate increase of 7% (for a 40-year-old non-smoker) across all plans and metal levels in the North Dakota exchange.
• 2016: Average increase of 12.2%. The overall weighted average rate increase in the North Dakota exchange was 12.2% for 2016, based on enrollment numbers as of September 2015.  It’s noteworthy that Blue Cross Blue Shield of North Dakota (the dominant carrier in North Dakota’s individual market, both on and off-exchange), was profitable across all lines of business in 2015 — a reversal of course for BCBSND, which had struggled with losses in 2013 when its subsidiary, Noridian, bungled a health insurance exchange platform that they were creating for Maryland (Maryland ended their contract with Noridian in early 2014 and started over with new exchange technology that they purchased from Connecticut). Average rate increases ranged from 8.5% for Sanford to 12.6% and 12.8% for BCBSND and Medica, respectively.
• 2017: Average increase of 1.3%. For 2017, Blue Cross Blue Shield of North Dakota implemented a small average rate decrease. BCBS of ND had the majority of the exchange’s enrollment, so their rate decrease meant that the overall average rate increase in North Dakota was just 1.3% for 2017, which was tied with Rhode Island as the lowest in the country, by far. The insurers in North Dakota’s exchange implemented the following average rate changes for 2017:
  • BCBS of ND: a 1.57% decrease 
  • Medica: 14.3% increase 
  • Sanford: 7.85% increase 
• 2018: Average increases ranged from 8% to 23%, and Medica left the exchange for one year. In October 2017, the North Dakota Department of Insurance announced that rates for 2018 individual and small group health insurance had been finalized. ND Insurance Commissioner, Jon Godfread, who is not a fan of the ACA, stated that “the heavy burdens created by Obamacare are continuing to force rates to significantly increase as time goes on,” but went on to say that the state was fortunate to still have a competitive market. The approved rates for 2018 were based on the assumption that CSR funding would continue, despite the fact that it was eliminated a few weeks before the start of open enrollment. And insurers in North Dakota were not allowed to revise their rates to account for the loss of CSR funding (this was an unusual approach, and is discussed in more detail further down this page; most states did allow insurers to revise rates at the last minute, once the CSR funding was eliminated). North Dakota’s exchange insurers implemented the following average rate increases for 2018:
  • Blue Cross Blue Shield of North Dakota (Noridian): 22.6% increase(BCBS/Noridian had 35,000 members, including on and off-exchange enrollment). 
  • Sanford: 7.9% increase (Sanford had 1,200 members). Sanford sharply reduced their coverage area for 2018, only offering plans in the Fargo and Bismark areas.
  • Medica: 18.8% increase. Medica’s plans are only available off-exchange for 2018, and not on-exchange. Medica tried to revise its proposed rate increase to be larger once it became apparent that Congress and the Trump Administration were not taking steps to commit to CSR funding for 2018, but their request was denied by the North Dakota Insurance Department, and Medica opted to exit the exchange as a result. Medica rejoined the exchange for 2019, when they were allowed to add the cost of CSR to silver plan rates.
• 2019: Average increase of 3.2%. The average rate increases for 2019 were announced by the ND Insurance Department in late September 2018, amounting to an overall average increase of 3.2%. BCBSND, Sanford, and Medica all continued to offer small group plans in the state, with modest rate increases. In addition, United Healthcare began offering small group health plans in North Dakota in 2019.
• 2020: Average decrease of 5.7%. Since rate filings for 2020 were due well before the state’s reinsurance proposal had gained federal approval, North Dakota’s insurance commissioner directed the state’s insurers to file two sets of rates: One based on reinsurance being enacted and the other based on the status quo. Once the federal government granted approval for the 1332 waiver, the North Dakota Insurance Department used the rate filings based on the reinsurance program being in place. The following average rate changes were approved for 2020 (all data are from North Dakota SERFF):
  • Medica: 17% decrease (Medica’s alternate filing was for a 3.9% rate increase if reinsurance hadn’t been approved; they had 373 members)
  • Blue Cross Blue Shield of North Dakota/Noridian: 1.7% decrease (Noridian’s alternate filing was for an 18.3% increase; they had 17,744 members)
  • Sanford: 14.4% decrease (Sanford’s alternate filing was for a 7% increase; they had 7,873 members)

  With the reinsurance program in place, North Dakota estimated that premiums in the individual market would be up to 20% lower than they would otherwise have been, which was very accurate: Overall, there was a weighted average rate decrease of 5.72% for 2020; without reinsurance, there would have been an average rate increase of about 14.65%.

  But it’s important to understand that these numbers are all referring to full-price premiums, which are only paid by about 13% of the state’s exchange enrollees (but by all of the off-exchange enrollees). When benchmark premiums decrease from one year to the next, premium subsidies decrease as well. So the change in a person’s net premium (ie, after their subsidy is applied) can be very different from the average premium changes for full-price plans.

  State officials also projected that with reinsurance in place, individual market enrollment would be 1% higher in 2020 than it would otherwise have been (this is because coverage is more affordable for people who don’t receive premium subsidies, since full-price premiums are lower). Enrollment in the exchange ended up being slightly lower in 2020 than it had been in 2019, but enrollment may have increased outside exchange. Reinsurance reduces premiums for everyone who buys coverage outside the exchange, since none of those enrollees qualify for premium subsidies.

• 2021: Premiums mostly flat. The 2021 rate increases that the North Dakota Insurance Department approved were much smaller than the insurers had initially proposed (the proposed rates amounted to overall average rate increases that ranged from about 4% to about 20%). After the rate review process was finalized, overall premiums for most enrollees were expected to remain very steady from 2020 to 2021. And increasing premium subsidies may have resulted in more affordable coverage for some enrollees, even before the American Rescue Plan further increased the subsidy amounts for 2021. The following overall average rate changes were approved for 2021:
  • Medica: 0.9% increase. Medica had 670 members in 2020 (about 300 more than the year before), and had proposed an average rate increase of more than 13%.
  • Blue Cross Blue Shield of North Dakota/Noridian: 0.63% increase. According to SERFF filing number NMIN-132390749, Blue Cross Blue Shield of ND had 23,248 members in ACA-compliant individual market plans as of 2020. But the North Dakota Insurance Department noted that they have about two-thirds of the state’s individual market share, which would amount to roughly 28,000 people. BCBSND had initially proposed an average rate increase of 4.42%.
  • Sanford: 14.28% increase. Sanford had 6,579 members in 2020 (about 1,300 fewer than the year before). This was a much more substantial average rate increase than we saw from most insurers around the country for 2021, but Sanford’s rate filing noted that their 2019 claims experience was worse than expected, they had to contribute more than expected to the federal risk adjustment program, and were receiving less than expected from North Dakota’s new reinsurance program (described below). The North Dakota Insurance Department clarified that Sanford had essentially underpriced their plans for 2020, which was why they approved a larger overall average increase for Sanford for 2021. Sanford had initially proposed an average rate increase of 20.33%.

  North Dakota’s Insurance Commissioner Jon Godfread clarified that North Dakota’s ACA-compliant individual market was split roughly equally between on-exchange and off-exchange enrollments, with about 21,000 people enrolled in on-exchange plans and about 21,000 enrolled off-exchange as of 2020.

  In mid-October 2020, just a couple of days before the North Dakota Insurance Department publicized the approved rate changes for 2021, CMS reported that the average benchmark premium in North Dakota (used to calculate premium subsidies) would increase by 29% for 2021. This was by far the largest across any of the states that use HealthCare.gov; the average was a 2% decrease, so North Dakota was certainly an outlier in that regard. However, Commissioner Godfread noted that it was possible that CMS had based that number on the proposed rate changes, which called for much more substantial rate increases than the Department ultimately approved.

  Godfread explained that for the most part, the approved rate increases for 2021 were attributed to the cost of cost-sharing reductions and thus applied only to on-exchange Silver plans. But due to Sanford’s prior year underpricing, a 7% average increase was also allowed for Sanford’s Gold plans, including on-exchange and off-exchange. Otherwise, there was no average rate increase for plans sold outside the exchange, and no average increase for Bronze plans or Gold plans other than Sanford’s.

  Due to the increasing Silver plan rates, premium subsidies did end up being significantly larger in North Dakota for 2021, even before the American Rescue Plan increased premium subsidies nationwide. The average subsidy amount in North Dakota was $323/month in 2020. During the open enrollment period for 2021 coverage (ie, before the American Rescue Plan’s impact on subsidies), the average subsidy in North Dakota’s exchange amounted to $420/month. It’s worth noting that enrollment reached a record high in North Dakota’s exchange during the open enrollment period for 2021 coverage; the larger subsidies and resulting increased affordability of non-silver plans may have played a role in that.

  Godfread noted that the state’s approach of holding premiums mostly unchanged for 2021 was taken instead of asking insurers to issue premium rebates in 2020 to address the fact that claims expenses were down in the 2nd quarter of 2020 as a result of the COVID pandemic (people were likely to delay medical care, resulting in lower overall premiums; this happened nationwide and insurers in some states have announced temporary premium cuts or rebates this fall to account for the outsized revenue they earned earlier this year). Godfread’s team felt that premium rebates would deplete insurers’ reserves, which might be problematic if claims increase above normal heading into 2021. So their approach was to use the rate approval process to keep premiums in the individual market largely unchanged for 2021, instead of approving rate increases.

  Godfread also noted that the state encourages people who don’t qualify for subsidies to shop off-exchange if they want Silver plans, as the cost of CSR is not added to off-exchange Silver plans. The cost difference between on-exchange and off-exchange Silver plans is be more pronounced in North Dakota for 2021, given the state’s approach to rate changes for 2021. But it’s worth noting that many people who didn’t previously qualify for subsidies do qualify for them as a result of the American Rescue Plan — which was enacted well after people had made their plan selections for 2021 coverage.

• 2022: The North Dakota Insurance Department announced the approved average rate changes in October 2021, amounting to an overall weighted average rate increase of about 1.24% for 2022, before any subsidies are applied.

A record-high 29,873 people enrolled in private plans (QHPs) through the North Dakota exchange during the open enrollment period for 2022 plans. Enrollment in North Dakota’s exchange had previously peaked in 2021, when 22,709 people enrolled.

North Dakota was one of only a handful of states where exchange enrollment increased every year from 2014 through 2018. In most states that use HealthCare.gov, peak enrollment initially occurred in 2016, with declining enrollment from then through 2020 (record-high enrollments were then the norm for 2022). In North Dakota, the first decline came in 2019 (South Dakota is the only other state with a fully HHS-run exchange where enrollment grew every year from 2014 through 2018).

Here’s a look back at enrollment numbers in North Dakota’s exchange from 2014 through 2021:

• 10,597 people had enrolled in private plans through the North Dakota exchange as of April 19, 2014. This was the lowest total of any state in the country, but it was still more than double the number of North Dakota residents who had enrolled as of March 1. And in sparsely populated North Dakota, it’s not surprising that enrollment was so low; only Vermont, Wyoming, Alaska, and DC have smaller populations than North Dakota.
• 18,171 people enrolled for 2015.
• 21,604 people enrolled for 2016.
• 21,982 people enrolled for 2017 (and average premiums decreased slightly, which was very rare nationwide in 2017).
• 22,486 people enrolled for 2018
• 21,820 people enrolled for 2019
• 21,666 people enrolled for 2020
• 22,709 people enrolled for 2021
• 29,873 people enrolled for 2022