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North Dakota did not establish its own exchange, so enrollments are completed via HealthCare.gov or an approved enhanced direct enrollment entity.
For 2023 coverage, there are three insurers that offer exchange plans in North Dakota. The overall approved average rate increase for 2023 was about 4.4%, before subsidies are applied.
The American Rescue Plan‘s subsidy enhancements have been extended through 2o25 by the Inflation Reduction Act, so subsidies continue to be larger and more widely available than they were prior to 2021.
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:
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:
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:
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.
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.
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:
North Dakota House Bill 1106, which called for the creation of a reinsurance program to stabilize the state’s individual insurance market, passed with unanimous support in the state House of Representatives in February 2019, and nearly unanimous (46-1) support in the Senate. It was signed into law by Governor Doug Bergum in April 2019, and heralded by Insurance Commissioner Jon Godfread as a measure that will “help ease the heavy burdens our health insurance market is facing.”
The legislation called for the state to create a reinsurance program that pays 75 percent of non-grandfathered individual market claims that exceed $100,000 — referred to as the attachment point. The reinsurance program will continue to pay three-quarters of the bill until the claim reaches $1 million (the $100,000 attachment point is higher than the attachment points being used in most of the other states that have created reinsurance programs, but the $1 million cap is also higher than the caps most of the other states have implemented).
North Dakota is one of 14 states that have implemented reinsurance programs using a combination of state funding and federal pass-through funding (Virginia will join them as of 2023). It’s called pass-through funding because it’s actually federal savings that are passed through to the state. Because reinsurance results in lower premiums, the premium tax credits (subsidies) are also smaller. That saves the federal government money, and states can use 1332 waivers that allow the state to keep the savings (rather than letting the federal government keep the savings) and use it to fund the reinsurance program.
For the state portion of the funding, North Dakota’s legislation calls for the state to impose an assessment on group health insurers in the state. This is a common approach that other states have successfully used (in most states, the federal pass-through funding covers the majority of the cost, but a state’s 1332 waiver proposal has to demonstrate how the state will fund its portion of the cost).
Once HB1106 was enacted, North Dakota submitted a 1332 waiver proposal to the federal government in May 2019. Approval was granted at the end of July, and North Dakota’s reinsurance program took effect as of 2020.
HB 1106 did not come as a surprise in 2019. Reinsurance has been gaining popularity as an option for stabilizing individual insurance markets around the country, and it’s something that North Dakota insurance regulators were discussing throughout 2018. In May 2018, North Dakota’s Insurance Commissioner, John Godfread, announced that the state’s insurance department would conduct a study to analyze various approaches to state-based health care reform.
Over the next few months, the state considered consider the possibility of expanding the existing high-risk pool, the Comprehensive Health Association of North Dakota (CHAND), as well as the possibility of implementing a state-based reinsurance program. The ACA included federal reinsurance, but it was temporary and expired at the end of 2016.
Godfread’s 2018 announcement also noted that the North Dakota Insurance Department was “analyzing Idaho’s state-based plan initiative and how a similar state-based plan allowance could operate in North Dakota. The state-based plan initiative would allow insurance carriers to offer plans, outside of the existing ACA exchange, that would be more flexible in how those plans are underwritten and designed.” It’s worth clarifying, however, that CMS blocked Idaho’s proposal, as it was not legal under the ACA.
But North Dakota was considering a modified version of what Idaho had planned to implement, as Godfread’s statement clarifies that the potential state-based plans in North Dakota “would still be required to offer all ACA mandated essential health benefits, be guaranteed issue, but would potentially allow for credits for healthy behavior or other health-related factors.”
In late September 2018, the North Dakota Insurance Department publicized their study findings. The study concluded that the two best options for North Dakota to pursue would be a state-based reinsurance program and the creation of state-based health insurance plans that insurers could sell outside the exchange. Ultimately, HB 1106 was introduced on January 3, as soon as the 2019 legislative session got underway, and was enacted in April.
For 2018, North Dakota and Vermont were the only states where insurers were not allowed to add the cost of cost-sharing reductions (CSR) to premiums, despite the fact that the Trump Administration stopped reimbursing insurers for the cost of CSR. In most states, the cost of CSR was added to silver plans, either across the full on- and off-exchange market, or only to the on-exchange market.
On October 12, 2017, after months of dithering with the issue, the Trump Administration announced that CSR funding would end immediately. That left some insurers and states scrambling to implement appropriate premiums for 2018. Although final rates had already been transmitted to HealthCare.gov at the end of September, HHS agreed to allow, on a case-by-case basis, some insurers to refile new rates with the cost of CSR included in the premiums. Specifically, insurers in states like North Dakota that did not allow a CSR load in the initially-approved rates, were allowed the opportunity to refile new rates if state regulators permitted it.
On October 16, North Dakota Insurance Commissioner John Godfread indicated that his office was determining what course of action to take regarding the lack of CSR funding. But on October 17, the North Dakota Insurance Department announced that the previously approved rate increases would remain in place, and that they would not allow North Dakota insurers to add the cost of CSR to their premiums for 2018 (North Dakota, DC, and Vermont were the only jurisdictions where insurers were prohibited from adding the cost of CSR to premiums for 2018).
As a result, Medica left the exchange in North Dakota at the end of 2017, rather than absorb the cost of CSR without being able to add it to 2018 premiums. And Sanford sharply reduced their on-exchange coverage area to just five counties, after offering plans statewide in previous years.
Consumers are best protected when insurers add the cost of CSR to on-exchange silver plans, and allow people the option of purchasing off-exchange silver plans that don’t have the cost of CSR added to the premiums. This allows premium subsidies to grow for everyone who gets premium subsidies, including people who purchase non-silver on-exchange plans that don’t have the cost of CSR added. For people who want a silver plan and who qualify for premium subsidies, the subsidies grow to cover the added cost of CSR. And for people who want silver plans but who don’t qualify for premium subsidies, the off-exchange silver plans are a good option, as they don’t have the added premium cost to cover CSR.
About a third of the states took that option for 2018, and North Dakota joined them for 2019 (as did several other states where the 2018 approach was to add the cost of CSR to all silver plan rates, including plans sold outside the exchange). The state’s rate filing instructions for 2019 directed insurers to add the cost of CSR to on-exchange silver plans, and to the identical silver plans that are sold off-exchange. But they also instructed insurers to file “corresponding” silver plans that would only be sold off-exchange, and that don’t have the cost of CSR added to premiums.
The North Dakota Insurance Department confirmed in May 2018 that their expectation was that Medica would once again be available on-exchange in 2019; that was confirmed when Medica’s redacted rate filing became available. And Sanford expanded their coverage area to the whole state, after limiting it sharply for 2018.
Vermont, which was the other state that didn’t allow insurers to add the cost of CSR to premiums for 2018, also instructed insurers to add the cost of CSR to on-exchange silver plans for 2019 (note that DC also prohibited insurers from adding the cost of CSR to premiums for 2018, but they only have a few hundred enrollees receiving CSR benefits, so the impact of the elimination of CSR funding has been negligible in DC).
Three organizations in North Dakota received a total of nearly $637,000 in navigator grants in 2015 that were used for outreach and enrollment efforts. The grants were awarded to Family HealthCare Center, Great Plains Tribal Chairmen’s Health Board, and Minot State University’s North Dakota Center for Persons with Disabilities. Residents in North Dakota can reach out to any of these organizations for in-person enrollment help.
The same three organizations again received nearly $637,000 in navigator grants in 2016. Residents in North Dakota can reach out to any of these organizations for in-person enrollment help.
The Trump administration began reducing navigator funding in 2017 and again in 2018. When navigator grants were announced in September 2018, only one organization in North Dakota — Family HealthCare Center — received $85,000.
But under the Biden administration, Navigator funding grew to record highs in 2021. In North Dakota, Minot State University received Navigator funding that amounted to nearly $1 million in 2021.
Following President Obama’s announcement in November 2013 that existing policies could be renewed into 2014 at the discretion of states and carriers, North Dakota’s then-Insurance Commissioner Adam Hamm decided to go along with the president’s policy cancellation “fix” and urged carriers to provide an option to renew some 36,000 individual policies that had been scheduled to terminate at the end of the year. The state has continued to go along with subsequent guidance from CMS that allows these plans to continue to renew.
But Blue Cross Blue Shield of North Dakota — the state’s largest insurer — opted in December 2014 not to continue to renew policies that had been scheduled for termination. Their insureds had the option to switch to a new ACA compliant BCBS plan, or purchase new coverage from another carrier for 2015.
So although grandmothered plans can continue to renew in North Dakota, Sanford is the only insurer that still had these plans in force as of 2021, and they only had 96 enrollees at that point, according to SERFF filing SANF-132869788.
State Exchange Profile: North DakotaThe Henry J. Kaiser Family Foundation overview of North Dakota’s progress toward creating a state health insurance exchange.
North Dakota Insurance Department
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
(701) 328-2440 / Toll Free: 800-247-0560 / [email protected]
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
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