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North Dakota and the ACA’s Medicaid expansion

North Dakota enacted legislation to continue Medicaid expansion

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 provided via Sanford Health Plan’s Medicaid managed care program.

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 Department of Human Services at 855-794-7308.

Legislation enacted 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 extends Medicaid expansion through July 2021. North Dakota has reauthorized Medicaid expansion again in 2021.

Dalrymple, whose final budget proposal included a recommendation to eliminate the sunset clause in the state’s Medicaid expansion, announced in 2015 that he would not seek reelection in 2016. His successor, Doug Burgum, took office in December 2016, and is also a Republican. 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. There are ongoing concerns that termination of Medicaid expansion in North Dakota — at either the federal or state level — could force hospitals, particularly in the state’s rural areas, to close. But thus far, lawmakers have continued to renew the state’s Medicaid expansion.

Costs higher than expected

As of September 2017, enrollment in North Dakota’s Medicaid expansion stood at fewer than 20,000 people. This was lower than the state had originally expected, but the overall cost of expanding Medicaid was higher than expected in North Dakota.  Sanford reported that the cost of claims among the Medicaid expansion group in 2014 averaged $1,215 per member, per month — far higher than the $352 average for their commercially-insured members.

Although the federal government paid the entire cost of providing coverage for the newly eligible population for the first three years, the state began paying 5% of the cost in 2017, and in 2020 and future years, the state will have to pay 10% of the cost.

Originally, the North Dakota Department of Human Services modeled their expansion plans on projections that the state would pay $2.9 million in Medicaid expansion costs during the first half of 2017. But by 2015, that projection stood at $8.2 million. Dalrymple’s final budget projected $30.5 million in state spending on Medicaid expansion from 2017 – 2019.

In March 2016, amid a budget shortfall, North Dakota called for Medicaid reimbursement cuts for providers, which also result in a reduction in federal Medicaid matching funds. At that point, enrollment in North Dakota’s expanded Medicaid was around 20,500 people, which was around the lower end of the state’s original estimate of how many people would become newly eligible for coverage under the expanded guidelines. As of September 2016, total enrollment in expanded Medicaid in North Dakota had declined slightly, and stood at 19,358.

ND1012, enacted in 2017 to extend Medicaid expansion through 2019, also called for using Medicaid expansion funding for the purpose of “establishing the provider fee schedule at the maximum level possible without exceeding the current levels of reimbursement for the Medicaid expansion contracted providers.”

Medicaid expansion benefits provided by Sanford Health Plan

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 awarded the state contract. Residents apply for and enroll in Medicaid expansion coverage through the state; Sanford does not determine eligibility. Once approved for Medicaid, enrollees can contact Sanford Health Plan with questions at [email protected] or call 855-305-5060 (Sanford member services).

The contract with Sanford expires in 2021 and cannot be extended. Accordingly, the state is seeking feedback and will issue a request for proposal to select a managed care organization to support the expansion population going forward.

North Dakota has accepted federal Medicaid expansion

  • 111,357 – Number of North Dakotans covered by Medicaid/CHIP as of May 2021
  • 41,377 – Increase in the number of North Dakotans covered by Medicaid/CHIP fall 2013 to May 2021
  • 30% – Reduction in the uninsured rate from 2010 to 2019
  • 59% – Increase in total Medicaid/CHIP enrollment in North Dakota since Medicaid expansion took effect

Who is eligible Medicaid in North Dakota?

Because North Dakota has expanded Medicaid under the ACA, low-income adults without dependent children are eligible for the first time in 2014.  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.

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 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

During the first open enrollment period (October 2013 through April 2014) 6,843 people in North Dakota enrolled in Medicaid or CHIP through, and another 2,013 people enrolled during the second open enrollment period. But people can enroll directly through North Dakota Medicaid as well, and enrollment in Medicaid and CHIP continue year-round; there’s no limited enrollment window.  From the fall of 2013 to May 2018, total Medicaid and CHIP enrollment in North Dakota increased by 38%, from 69,980 to 96,276 enrollees.

As of May 2021, North Dakota’s Medicaid and CHIP enrollment was 111,357.

According to U.S. Census data, the uninsured rate in North Dakota fell from 10.4% in 2013 to 7.9% in 2014; a 24% reduction. But from 2014 to 2015, North Dakota was one of just three states that did not experience a statistically significant change in uninsured rate, according to census data released in September 2016. By 2016, the uninsured rate had dropped only slightly, to 7%. Since coronavirus emerged in the U.S., uninsured rates have jumped in every state but Nebraska where the rate unchanged from 2018 to 2020. In North Dakota, the uninsured rate for non-elderly adults was 11% as of May 2020.

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 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 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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