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North Dakota and the ACA’s Medicaid expansion

North Dakota uses Medicaid managed care for most expansion enrollees, but 19- and 20-year-olds are covered under fee-for-service Medicaid

ACA’s Medicaid eligibility expansion in North Dakota

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North Dakota opted to accept federal funding to expand Medicaid under the Affordable Care Act. Medicaid expansion was passed by the North Dakota Legislature and signed into law by former Governor Jack Dalrymple in April 2013. Dalrymple was generally opposed to the Affordable Care Act (ACA), but he was the fourth Republican Governor to throw support behind the expansion of Medicaid in early 2013. Enrollment began in October 2013, with coverage effective January 2014.

Medicaid expansion in North Dakota is managed by Blue Cross Blue Shield of North Dakota (this is as of 2022; prior to that, the managed care contract was with Sanford Health Plan).

The state has also considered the possibility of administering the program itself instead of using the managed care model (as it does for traditional Medicaid), but has not moved forward with this and the managed care model has been reauthorized through March 2024. However, 19- and 20-year-olds have been moved from the managed care Medicaid expansion population to traditional fee-for-service Medicaid in North Dakota.

The state has created a helpful brochure to answer questions and provide information about Medicaid expansion. If you have other questions, you can contact the North Dakota Department of Human Services at 855-794-7308.

How will North Dakota handle Medicaid renewals after the pandemic?

Throughout the COVID pandemic, the Families First Coronavirus Response Act has been providing states with additional federal Medicaid funding, but has also prevented states from disenrolling anyone from Medicaid. As a result, Medicaid enrollment has trended steadily upward nationwide, reaching nearly 91 million people by the fall of 2022.

The pause on disenrollments was initially supposed to continue until the end of the COVID public health emergency, which has been repeatedly extended in 90-day increments throughout the pandemic. But the spending bill that was enacted in late 2022 delinked the Medicaid continuous coverage requirements from the public health emergency. The continuous coverage requirement now has an end date of March 31, 2023. So starting April 1, 2023, states can begin disenrolling people who are no longer eligible for Medicaid. This will be an ongoing process that lasts for up to 14 months, so some people will not receive eligibility redetermination packets for several months.

North Dakota’s Medicaid has partnered with a communications firm to provide outreach and information about the return to regular eligibility renewals. The state Department of Health and Human Services also has a webpage with information for enrollees about what to expect during the unwinding of the continuous coverage rules.

Enrollees need to make sure that their contact information is updated with the state Medicaid office, and watch their mail for any renewal information. If a renewal packet is sent to them requesting more information, they need to reply promptly, as states will not be able to renew coverage if they cannot verify that the person is still eligible for Medicaid.

Legislation to extend Medicaid expansion

Medicaid expansion in North Dakota was scheduled to expire at the end of July 2017, based on the initial legislation that state lawmakers passed in 2013. But the state enacted legislation (H.B.1012) in 2017 that extended the program through July 2019, and enacted additional legislation (S.B.2012) in 2019 that extended Medicaid expansion through July 2021. North Dakota enacted legislation (H.B.1012) in 2021 that reauthorized Medicaid expansion through June 2023.

North Dakota Governor Doug Burgum does not support the ACA, but clarified in November 2016 that he would be open to the possibility of extending Medicaid expansion in North Dakota temporarily, although his hope was that a new solution would be devised at the federal level. In late 2017, Burgum and 19 other Republican governors wrote a letter to Congress, urging lawmakers to repeal the ACA. At that point, the replacement bill under consideration (the American Health Care Act, or AHCA) would have resulted in significant federal funding cuts for Medicaid expansion.

Burgum’s first budget proposal, which was unveiled in mid-January 2017, called for continued funding for Medicaid expansion in North Dakota. Democratic-NPL leaders in North Dakota expressed support for Burgum’s inclusion of Medicaid expansion funding in the budget proposal. And, lawmakers have continued to renew the state’s Medicaid expansion.

Medicaid expansion benefits provided by Blue Cross Blue Shield of North Dakota as of 2022

North Dakota allowed private carriers to bid for the job of using federal Medicaid funds to provide health coverage to the newly eligible population. Two carriers — Sanford Health Plan and Blue Cross Blue Shield of North Dakota — placed bids, and Sanford was initially awarded the state contract. But the contract switched to Blue Cross Blue Shield of North Dakota as of 2022.

Residents apply for and enroll in Medicaid expansion coverage through the state; BCBSND does not determine eligibility. Once approved for Medicaid, enrollees can contact BCBSND with questions and use the member portal to learn about benefits, get paid for completing a health assessment, and get in touch with a customer service representative.

North Dakota has accepted federal Medicaid expansion

  • 126,291 – Number of North Dakotans covered by Medicaid/CHIP as of September 2022
  • 56,311 – Increase in the number of North Dakotans covered by Medicaid/CHIP fall 2013 to September 2022
  • 30% – Reduction in the uninsured rate from 2010 to 2019
  • 80% – Increase in total Medicaid/CHIP enrollment in North Dakota since Medicaid expansion took effect

Who is eligible for Medicaid in North Dakota?

Because North Dakota has expanded Medicaid under the ACA, low-income adults are eligible for coverage even if they don’t have minor children. Medicaid is available to the following legally present North Dakota residents, contingent on immigration guidelines:

  • Adults with household income up to 138% of federal poverty level (income limits for various family sizes are here).
  • Children age 0 – 18 with household income up to 170% of poverty.
  • Pregnant women with household income up to 157% of poverty; postpartum coverage now continues for 12 months, instead of ending 60 days after the baby is born.

Enrollment in Medicaid and CHIP continue year-round; there’s no limited enrollment window. North Dakota updates Medicaid eligibility rules on April 1 each year, using the federal poverty level numbers that were published earlier that year, in mid-late January (for the first three months of the year, the prior year’s federal poverty level numbers are used).

How does Medicaid provide financial assistance to Medicare beneficiaries in North Dakota?

Many Medicare beneficiaries receive Medicaid’s help with paying for Medicare premiums, affording prescription drug costs, and covering expenses not reimbursed by Medicare – such as long-term care.

Our guide to financial assistance for Medicare enrollees in North Dakota includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

How do I enroll in Medicaid in North Dakota?

Medicaid enrollment is year-round; you do not need to wait for an open enrollment period to apply for Medicaid.

  • North Dakota uses the federal health insurance marketplace, so you can enroll through HealthCare.gov or use their call center at 1-800-318-2596 (only use this option if you are under 65 and don’t have Medicare)
  • You can use the North Dakota Department of Human Services website to enroll online directly through the state.
  • You can print a paper application and submit it to your local County Social Services Office.
  • You can call or visit your Human Services Zone office (click on your county to see contact information) for in-person or phone assistance with enrollment

North Dakota Medicaid enrollment numbers

From the fall of 2013 to September 2022, total Medicaid and CHIP enrollment in North Dakota increased by 80%, from 69,980 to 126,291 enrollees.

The increase was primarily due to Medicaid expansion and the COVID pandemic. During the pandemic, states have been receiving additional federal Medicaid funding, but have not been allowed to disenroll anyone from Medicaid. But starting in April 2023, states will resume regular Medicaid eligibility redeterminations and will disenroll people who are not eligible. This is expected to result in a somewhat significant reduction in the number of people enrolled in Medicaid, although that drop-off will occur gradually over a 12-month period that begins in the spring of 2023.


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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Apply for Medicaid in North Dakota

Online at HealthCare.gov or the North Dakota Department of Human Services website.  You can also enroll by phone at 1-800-318-2596, or you can apply in person or by mail at your local County Social Services Office.

Eligibility: The aged, blind, and disabled.  Also, adults are eligible with household incomes up to 138% of poverty, and pregnant women with incomes up to 147% of poverty.  Children are eligible for Medicaid or CHIP with with household incomes up to 170% of poverty.

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