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North Dakota health insurance marketplace: history and news of the state’s exchange

Medica rejoined North Dakota's exchange for 2019

Highlights and updates

North Dakota exchange overview

North Dakota did not establish its own exchange, so enrollments are completed via

North Dakota insurers adding CSR cost to Silver plans for 2019; Medica rejoined the exchange

For 2018, North Dakota was one of only two 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. As a result, Medica left the exchange in North Dakota, rather than absorb the cost of CSR without being able to add it to premiums.

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 is joining them for 2019. The state’s rate filing instructions 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 will only be sold off-exchange, and that don’t have the cost of CSR added to premiums.

The North Dakota Insurance Department confirmed in late May that their expectation was that Medica would once again be available on-exchange in 2019, and that was confirmed when Medica’s redacted rate filing became available.

Vermont, which was the other state that didn’t allow insurers to add the cost of CSR to premiums for 2018, has 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 is negligible in DC).

Three insurers offering 2019 plans

With Medica’s return to the exchange, North Dakota will once again have three insurers offering individual market plans in the exchange.

Their average rate increases for 2019 were announced by the ND Insurance Department in late September:

  • Blue Cross Blue Shield of North Dakota (Noridian Mutual): On-exchange, the average rate increase is 2.29 percent, and off-exchange, it’s 1.43 percent (the proposed average rate increase across all plans was 5.79 percent, but that was reduced during the rate approval process). Carriers can offer different plans on- and off-exchange, but BCBSND’s rate filing indicates that the cost of CSR is being added to both on- and off-exchange silver plans, and the wording of the filing indicates that BCBSND did not opt to create different silver plans to be sold only off-exchange for 2019.
  • Medica: On-exchange, the average rate increase is 25.99 percent. Off-exchange, it’s 23.03 percent (the proposed average rate increases ranged from 16.3 percent to 29.9 percent). Medica only has 559 enrollees in 2018, since they only offer off-exchange plans this year. Enrollment is likely to increase in 2019 when they’ll once again be available on-exchange
  • Sanford: On-exchange, the average rate increase is 21.53 percent, while off-exchange it’s just 7.6 percent (proposed average rate increases ranged from 28.7 percent to 34.5 percent). Sanford had 3,300 members as of early 2018. The cost of CSR is being added only to on-exchange silver plan rates, and Sanford will offer four off-exchange-only silver plans that don’t include the cost of CSR in their rates. In 2018, when most other states allowed insurers to add the cost of CSR to silver plans rates, many insurers opted to add the cost only to on-exchange silver plan rates and offer different off-exchange silver plans without the cost of CSR added to the premiums. In those cases, there was a significant difference between the on- and off-exchange average rate increases. But 2019 is the first time that North Dakota insurers are being allowed to add the cost of CSR to premiums.

BCBSND, Sanford, and Medica will all continue to offer small group plans in the state, with modest rate increases. In addition, United Healthcare will begin offering small group health plans in North Dakota in 2019.

North Dakota analyzed options for market stabilization, legislation expected in 2019

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. Godfread was in favor of the ACA repeal bills that Congress considered in 2017, particularly the Graham-Cassidy legislation that was considered in September. The announcement referred to the 2017 GOP efforts to repeal the ACA as “meaningful reform” and noted that since those efforts fell short, the state would consider what other options are available. It’s noteworthy, however, that the Congressional Budget Office projected that if the Graham-Cassidy legislation has been enacted, millions of additional people would have joined the ranks of the uninsured.

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. Alaska, Minnesota, and Oregon have all implemented state-based reinsurance programs, which have served to stabilize their markets and keep premium increases in check. WisconsinMaineMaryland, and New Jersey received approval for their 1332 reinsurance waivers in 2018, and will implement reinsurance programs in 2019, helping to stabilize their individual markets.

Godfread’s 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 is 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 published 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. The Insurance Department plans to develop legislative proposals that could be considered by lawmakers during the 2019 legislative session, in hopes that market stabilization measures could be taken in time for the 2020 plan year.

1332 waiver proposals for reinsurance programs were approved very quickly in 2018 for the states that proposed them, allowing those states to receive federal pass-through funding to cover a portion of the cost of implementing reinsurance programs. So if North Dakota lawmakers approve a reinsurance program proposal, a 1332 waiver proposal for federal funding is likely to gain approval (the sticking point for some states’ legislatures has been how to fund the state’s portion of the cost, so it remains to be seen whether lawmakers in North Dakota will pass reinsurance legislation in 2019).

The proposed reinsurance program would have a higher attachment point than most other states (that have existing or impending reinsurance programs) have used, with reinsurance coverage kicking in once a claim reaches $100,000 or $200,000. But the reinsurance program would then cover 75 percent of the claim up to $1 million, which is more generous on the upper end than the average reinsurance program.

The state-based plan concept will be a more innovative solution that hasn’t been tested in other states, and it’s unclear whether federal approval would be forthcoming. North Dakota’s proposal is different from Idaho’s proposal (which was rejected by the Trump Administration) in several key ways, but it would allow plans to have higher cost-sharing than ACA-compliant plans and would allow healthy individuals to pay lower premiums, and would allow insurers to impose waiting periods if an applicant had a gap in coverage. But the state-based plans would be guaranteed-issue, cover all of the ACA’s essential health benefits, and would be part of the same risk pool with the ACA-compliant plans. The state would need to obtain federal approval to implement this concept.

2018 enrollment hits a record high in North Dakota

Open enrollment for 2018 coverage began on November 1, 2017, and ended on December 15, 2017. This was the first time that enrollments were not allowed (without a qualifying event) after the start of the new year. All plans purchased during open enrollment took effect January 1, 2018.

During the open enrollment period for 2018 coverage, 22,486 people enrolled in coverage through the North Dakota exchange. That’s more than 2 percent higher than the 21,982 people who enrolled the previous year, despite the fact that open enrollment for 2018 was half as long as it had been in prior years. North Dakota is one of at least 16 states that ended up with more people enrolled in exchange plans for 2018 than they had in 2017.

And total enrollment at the end of open enrollment was also higher in 2017 in North Dakota than it had been for 2016, which diverged from the declining enrollment trend that most states saw in 2017. So North Dakota bucked the trend two years in a row, with increasing enrollment despite funding cuts for exchange marketing and outreach, and despite the shorter enrollment period for 2018 coverage.

In fact, North Dakota is one of only a handful of states where exchange enrollment has steadily increased each year since 2014, and it’s one of only two such states (the other is South Dakota) where the exchange is fully run by HHS. In general, states that use the federally-run exchange system have seen at least some declines in enrollments from one year to the next, but North Dakota has not.

HHS estimated that there were 4,000 people in North Dakota who had off-exchange coverage in 2016, but who would be eligible for subsidies if they switched to exchange plans. During open enrollment, or during a special enrollment period triggered by a qualifying event, people can switch to any plan they like, on or off-exchange (most special enrollment periods apply off-exchange, but a few do not).

Medica exited ND’s exchange at the end of 2017

On September 28, 2017, the North Dakota Insurance Department announced that Medica would withdraw from the exchange at the end of the year. There were 20,691 North Dakota residents with effectuated exchange coverage in 2017, and 3,073 of them had coverage with Medica. So about 15 percent of the exchange enrollees had to either switch to off-exchange plans for 2018 (paying full-price, as subsidies aren’t available off-exchange), or switch to a plan from another exchange insurer during.

Medica enrollees who had on-exchange coverage and who didn’t pick a replacement plan in the exchange by December 15 were mapped to a replacement plan by the exchange, so that they wouldn’t become uninsured as of January 1. But those individuals also had until March 1, 2018 to pick their own replacement plan for the remainder of 2018, as they were eligible for a special enrollment period triggered by loss of coverage.

Medica has previously filed rates for plans to be offered in the North Dakota exchange for 2018, based on the assumption that the federal government would continue to fund cost-sharing reductions (CSR) in 2018 (CSR reduce out-of-pocket costs for lower-income enrollees with silver plans in the exchange; the federal government pays insurers to provide these better benefits, but ongoing funding for this was in question throughout 2017, and the Trump Administration ultimately eliminated the funding in mid-October 2017; insurers are still obligated to provide CSR benefits to eligible enrollees).

As the uncertainty around ongoing federal funding for CSRs continued to mount — and neither Congress nor the Trump Administration did anything to commit CSR funding for 2018 — Medica asked the North Dakota Insurance Department to approve new rates with a larger increase based on the assumption that CSR funding wouldn’t continue in 2018.

The Insurance Department felt that they had to err on the side of caution in terms of protecting state residents, since they didn’t have a way of reversing the higher rates if it later became apparent that CSR funding would continue, which we now know did not end up happening. (Some states found ways around this even before the Trump Administration clarified that CSR funding would end — Washington is an example — while other states allowed insurers to assume CSR funding wouldn’t continue and said they would let the rates eventually sort themselves out in the form of MLR rebates and potential rate decreases for 2019 if CSR funding had continued). So the Insurance Department rejected Medica’s request to add an additional load to the premiums to fund CSRs.

As a result, Medica informed the Insurance Department that they wouldn’t offer coverage in the exchange for 2018. People were still able to purchase individual market Medica plans off-exchange in North Dakota, but premium subsidies (and CSR) are not available off-exchange.

Almost all states allowed insurers to file rates that assume CSR funding would not continue in 2018, but Vermont took the same approach as North Dakota, and did not allow insurers to adjust rate filings to add a CSR load (but both of Vermont’s insurers remained on the exchange for 2018).

Rate increases for 2018 were slightly lower than insurers proposed

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, states 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 is fortunate to still have a competitive market (it’s worth noting that while the ACA does need fixes, many of the factors that have driven rates higher over the last few years are related to long-term GOP sabotage, and the situation in 2017 caused by the Trump Administration and the GOP efforts to repeal the ACA).

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. North Dakota’s exchange insurers implemented the following average rate increases for 2018:

  • Blue Cross Blue Shield of North Dakota (Noridian): 22.6 percent (proposed increase was 24 percent; BCBS/Noridian has 35,000 members, including on and off-exchange enrollment). BCBSND is offering coverage statewide.
  • Sanford: 7.9 percent (proposed increases were 10 percent to 13 percent, depending on the plan; Sanford has 1,200 members). Sanford offers coverage in the Fargo and Bismark areas.
  • Medica: 18.8 percent (approved as proposed, but only available off-exchange). Medica’s plans are only available off-exchange for 2018, and not on-exchange. Medica tried to revise their 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 (3,975 members, most of whom — 3,073 — had on-exchange coverage and needed to either switch to off-exchange plans or pick a 2018 plan from BCBSND or Sanford in order to retain on-exchange coverage and the associated premium subsidies and cost-sharing subsidies)

For both Blue Cross Blue Shield of North Dakota and Sanford, the approved final rate increases were slightly lower than the insurers proposed. Sanford’s rate increase was in the single digits, but they have a very small segment of North Dakota’s ACA-complaint individual market (1,200 out of 42,000 total in 2017).

Fewer than half of the ACA-compliant individual market enrollees in North Dakota had coverage through the exchange as of 2017 (20,691 had on-exchange coverage). Of the exchange enrollees, 85 percent were receiving premium subsidies that grew larger to offset the rate increases for 2018. But it was essential for enrollees to comparison shop during open enrollment for 2018 coverage, especially since the rates for BCBSND increased so much more than the rates for Sanford. If a different plan takes over in a particular area as the second-lowest-cost silver plan, subsidy amounts in that area end up being tied to the new plan, and people who didn’t comparison shop might have found that their after-subsidy premiums were significantly higher in January.

In the small group market, the average approved rate increases for 2018 range from 2.3 percent to 11.8 percent.

ND insurers were not allowed to refile rates after CSR funding was cut

North Dakota is one of a handful of states where the approved rate increases for 2018 were based on the assumption that CSR funding would continue. As noted above, Medica chose to exit the exchange altogether when the state wouldn’t let them add the cost of CSR to their plans.

On October 12, 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 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 released a statement explaining that the previously approved rate increases would remain in place, and that he would not allow North Dakota insurers to add the cost of CSR to their premiums for 2018.

In hindsight, that makes Medica’s decision particularly prescient. And it raised the question of what BCBSND and Sanford would do next. Technically, both insurers had the option to exit the exchange, despite signing a contract with in late September. That’s because the contract contains an exit clause that’s triggered in the event that CSR funding doesn’t continue. A few days after CSR funding was eliminated, Sanford’s Executive Vice President, Kirk Zimmer, said “We have to balance our decision on what’s best for all our members. There are a lot of ideas being floated that may impact how we move ahead. We are still weighing all of our options.” Ultimately, both BCBSND and Sanford remained in the exchange for 2018.

Godfread is one of very few insurance commissioners around the country who refused to allow insurers to add the cost of CSR to premiums for 2018, and he’s certainly not a supporter of the ACA. Adding the CSR load to premiums makes it more feasible for insurers to remain in the exchange, and most consumers are protected from the higher rate increases by premium subsidies that grow larger when the cost of CSR is added to silver plan premiums. 85 percent of North Dakota exchange enrollees were receiving premium subsidies in 2017. If the state had allowed insurers to add the cost of CSR to premiums, those enrollees would have been mostly protected. The other 15 percent, plus off-exchange enrollees, would also have been mostly protected as long as the CSR cost was added only to silver plans.

But instead, the originally approved rates took effect January 1. Nearly half (47 percent) of North Dakota’s exchange enrollees were receiving CSR in 2017. Sanford and BCBSND still have to provide CSR benefits to these enrollees, but they are no longer receiving federal funding to cover the cost, and they were not allowed to add the cost to their premiums, as insurers would normally do to cover an anticipated loss.

Although the Trump Administration has cut off CSR funding, Congress could undo that by simply allocating the funding — as they could have done at any point during 2017. In September, Republican leadership in the Senate scuttled bipartisan efforts to fix the ACA in favor of their last-ditch ACA repeal bill that ultimately failed. But on October 17, the bipartisan bill was resurrected, and Senators Patty Murray (D, WA) and Lamar Alexander (R, TN) announced that they had reached a compromise that would allow continued funding for CSRs for two years.

That effort did not go anywhere though, and funding CSR is no longer a priority for Democrats. That’s because the solution that most states have implemented — adding the cost of CSR to silver plan premiums — ends up protecting consumers and insurers, and many consumers end up better off than they would have been if CSR funding had been allocated, since premium subsidies are so much larger. Presumably, North Dakota will allow insurers to add the cost of CSR to premiums for 2019, as the situation will no longer be speculative at that point.

North Dakota exchange and the Trump Administration

There is considerable uncertainty about the future of the ACA and the stability of the individual health insurance market under the Trump Administration. Republicans in Congress tried throughout 2017 to repeal the ACA, although their efforts fell short.

But even with no legislation to repeal the ACA, the stability of the insurance markets is in question. Two pressing issues for insurers are the enforcement of the individual mandate, and continued federal funding for cost-sharing reductions. The Trump Administration has called for relaxed enforcement of the individual mandate, and announced in October 2017 that funding for cost-sharing reductions (CSR) would end immediately.

In general, the insurance markets had been looking fairly stable heading into 2018, but the Trump Administration has effectively destabilized it. In states where insurers have been allowed to add the cost of CSRs to silver plan rates (particularly for only on-exchange silver plans, as is the case in California), consumers are fairly well protected, as are insurers. That’s because the higher rates for silver plans (which are the only plans to which CSRs apply) will result in larger premium subsidies. That will protect silver-plan enrollees who receive premium subsidies, and it would make bronze, gold, and platinum coverage relatively more affordable for those who receive premium subsidies, as they can apply the larger subsidies to metal level plans that aren’t impacted by the higher CSR load. Insurers are also protected, as the cost to provide CSRs will be worked into their premiums.

In North Dakota, however, regulators have opted to not allow insurers to add any additional premiums to account for the discontinuation of CSR funding by the federal government. The result is Medica’s exit from the exchange, and the potentiality that BCBSND and Sanford might follow suit now that it appears that their premiums for 2018 will be inadequate.

2017: lower prices and higher enrollment, both in contrast with most of the rest of the country

The majority of North Dakota exchange enrollees saw a small average rate decrease for 2017, which was extremely rare this year (overall, there was a slight increase in weighted average premiums, but the small decrease applied to the majority of enrollees; details below).

21,982 people enrolled in qualified health plans through the North Dakota exchange during the 2017 open enrollment period, which ended January 31, 2017. That’s a 1.7 percent increase over the 2016 enrollment total. Across all states that use, there was an average decrease in enrollment of about 5 percent from 2016 to 2017, but North Dakota bucked that trend. The lower premiums were likely a factor, as rates in most other states increased significantly for 2017.

As of February 2017, there were 20,306 people with effectuated coverage in individual market plans through North Dakota’s exchange. 85 percent of them were receiving premium subsidies.

19,358 people were enrolled in North Dakota’s expanded Medicaid as of September 2016. The state had estimated that 20,500 people would be eligible for expanded Medicaid, and the enrollment total had leveled off in 2016, a little below that amount.

2017 rates and carriers

There are three carriers that offer plans in the North Dakota exchange. BCBS of ND and Sanford offer coverage statewide, while Medica offers coverage everywhere except four counties in the northwest corner of the state. Their average

Average rate increases for 2017 were all smaller than the carriers had proposed:

  • BCBS of ND: a 1.57 percent decrease (the carrier had proposed a 1.82 percent rate increase).
  • Medica: 14.3 percent increase (the carrier had proposed a 16.9 percent rate increase)
  • Sanford: 7.85 percent increase (the carrier had proposed a 10.7 percent rate increase)

North Dakota regulators approved rates that were lower than requested, just as they did the year before. For 2016, BCBS of ND and Medica both proposed rate hikes of more than 16 percent, but state regulators trimmed them down to under 13 percent.

BCBS of ND has the majority of the exchange’s enrollment, so their small rate decrease means that the overall average rate increase in North Dakota is just 1.3 percent, which was tied with Rhode Island as the lowest in the country, by far.

BCBS of ND’s CEO, Tim Huckle, noted that “financially, [BCBSND was] having another solid year” in 2016. Huckle also explained that premiums in North Dakota were probably more realistic in 2014 than they were in other states (where they were too low), which helped to prevent huge rate increases in the ensuing years.

Sanford had 4,310 enrollees in the North Dakota exchange as of August 2016, and 1,170 off-exchange enrollees. They noted that while most of their off-exchange enrollees had ACA-compliant plans, the off-exchange total also included their remaining grandfathered and transitional enrollees.

The average benchmark plan (second-lowest-cost silver) premium in North Dakota is 7 percent higher in 2017, so subsidies are a little larger in 2017 to offset the higher benchmark premiums. For comparison, across all the states that use, the average benchmark premium increase was 22 percent.

2016 enrollment

21,604 people enrolled in private plans through the North Dakota exchange during the 2016 open enrollment period. That was a 19 percent increase over 2015, when 18,171 people selected private plans through the exchange.

By March 31, effectuated enrollment in the North Dakota exchange stood at 20,536. Nearly 86 percent of the effectuated enrollees are receiving premium subsidies to offset the cost of their coverage. The average premium subsidy in North Dakota is $262 per month, and the average after-subsidy premium is $142 per month.

More than 7,500 enrollees in North Dakota were new to the exchange for 2016. Total enrollment in private plans through the exchange in North Dakota is lower than every other state except Hawaii, but that’s to be expected given North Dakota’s low population and small number of people eligible to shop in the exchange.

Open enrollment for 2016 coverage ended on January 31. The next open enrollment period – for coverage effective in 2017 – will begin on November 1. Between now and then, enrollment is only available if you have a qualifying event (Native Americans can enroll year-round without a qualifying event, and so can enrollees who are eligible for Medicaid or CHIP).

2016 rates and carriers

There are three carriers in the North Dakota exchange offering plans for 2016; all of them also offered plans in 2015 and 2014. Blue Cross Blue Shield of North Dakota and Medica had both proposed rate hikes in excess of 16 percent, but regulators trimmed the approved rate increases down to less than 13 percent for each of them. Sanford’s proposed rate increase was approved without changes. For 2016, here are the average rate increases for each of the North Dakota exchange carriers:

  • BCBS of ND: 12.6 percent rate increase (a reduction from the 18.4 percent rate hike they requested)
  • Medica: 12.8 percent rate increase (a reduction from the 16.5 percent rate hike they requested)
  • Sanford: 8.49 percent rate increase (approved as requested).

As of September 2015, the North Dakota Insurance Department reported that effectuated enrollment through the exchange was:

  • BCBS of ND = 11,705 members
  • Medica = 3,067 members
  • Sanford = 1,894 members according to ND Ins. Dept (according to Sanford, the count is a little lower, at 1,772).

The overall weighted average rate increase in the North Dakota exchange for 2016 was 12.2 percent, using the market share numbers from September. That’s significantly better than it would have been (nearly 17 percent) if rates had been approved as-requested.

And the 12.2 percent average rate increase is based on the assumption that everyone kept the same plan they had in 2015; shopping around results in different effective rate changes (nationwide, the average rate change if people kept their 2015 plans was around 12 to 13 percent. But when we account for plan changes, it was more like 9 percent).

According to HHS, the average benchmark premium in North Dakota is 8.9 percent higher in 2016 than it was in 2015. Since benchmark plans aren’t necessarily the same plan from one year to the next, that number doesn’t give us much data in terms of how rates have changed for people who kept their 2015 plans.

But it does tell us that subsidies are higher on average than they were in 2015 in North Dakota. So subsidies are offsetting some of the rate increase for enrollees who are subsidy-eligible.

2016 off-exchange average rate hike 12.4%

Time Insurance Company (which offered off-exchange plans in 2015 in North Dakota) initially proposed significant rate hikes, but it was subsequently announced that the parent company – Assurant – would exit the health insurance market nationwide, and would not offer plans for 2016.

According to rate filing data submitted by the carriers in the spring of 2015, BCBS of ND had roughly 29,000 members, and Medica had 4,778 members. Sanford’s filing was for a rate hike of less than ten percent, so it wasn’t made public until the end of October – and it didn’t include total market share numbers. But according to Sanford, they had 267 off-exchange members as of September 2015, and a total enrollment of 2,039 people, including exchange enrollments.

Based on these numbers, the overall weighted average rate increase in the combined ACA-compliant individual market in North Dakota is 12.4 percent.

BCBS of North Dakota profitable in 2015

Blue Cross Blue Shield of North Dakota is the dominant carrier in North Dakota’s individual market, both on and off-exchange. And in 2015, the carrier was profitable across all lines of business – 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.

BCBSND’s profitability – including in the individual market – is in contrast to many carriers across the country, where individual market losses were common in 2015.

Sanford, another North Dakota insurer, posted a $76.5 million loss for 2015, but half of that was money set aside to cover anticipated losses in 2016. Sanford’s losses stemmed from their new contract to cover the state’s Public Employees Retirement System group, which BCBSND handled for 37 years until Sanford got the contract in 2015. Sanford also experienced higher-than-expected claims in the individual market in North Dakota, which was generally the case with most insurers nationwide in 2015.

Navigator grants

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.

2015 enrollment

During the 2015 open enrollment period, 18,171 people completed their private plan enrollments in the North Dakota exchange, including 10,080 who renewed 2014 coverage (55 percent of the 2015 total were people who already had coverage in the exchange in 2014). HHS had predicted a total enrollment of 14,000 people by the end of the 2015 open enrollment, so the exchange ended up at almost 130 percent of their target.

86 percent of the residents who finalized their enrollments for 2015 were eligible for premium subsidies.

In addition to the private plan enrollments, 2,013 North Dakota residents enrolled in Medicaid or CHIP through between November 15 and February 22.

By June, HHS reported that North Dakota’s exchange had 16,651 effectuated (in-force, paid-up) private plan enrollments. Attrition is a normal part of the individual insurance market, and enrollment is generally expected to decline slowly throughout the “off season” outside of open enrollment. But according to the ND Insurance Department, effectuated enrollment climbed slightly from June to September, with 16,666 people covered under effectuated policies by mid-September 2015.

Subsidies safe in North Dakota

The Supreme Court issued a ruling in King v. Burwell in June 2015, and the Justices upheld the legality of subsidies in every state, including those that use the federal marketplace ( That means subsidies were safe for 14,244 people in North Dakota in 2015, and will continue to be available going forward. For people who were receiving subsidies in 2015, losing them would have boosted premiums by an average of 169 percent – making coverage unaffordable in many cases.

Even for people who don’t get subsidies, the outcome of a plaintiff win in King v. Burwell would have been grim: The American Academy of Actuaries estimates that premiums in the entire individual market in impacted states would have increased by at least 35 percent, and possibly as high as 55 percent – in addition to the regular annual rate increases based on medical cost inflation.

Insurers in North Dakota expressed relief that subsidies were upheld, and the ruling is certainly good news for insureds and medical providers. Not surprisingly, however, North Dakota political leaders’ reaction to the ruling was generally split along party lines, with Republicans tending to express disappointment and continuing their call for full repeal of the ACA.

Rates and carriers for 2015

Open enrollment for 2015 started on November 15, 2014, and continued until February 15 (February 22 with the extension that was added for people who had tried to enroll by the deadline). The North Dakota Insurance Department has a healthcare reform page on their website that includes useful information for consumers, including a list of all the North Dakota brokers and agents who are certified to assist people with exchange enrollments.

Three carriers offered policies in the federally-run North Dakota exchange for 2015. This was unchanged from 2014, and included Blue Cross Blue Shield of North Dakota, Medica and Sanford. But while the three carriers offered a total of 21 plans in 2014, they offered a total of 30 options for 2015.

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 percent in North Dakota. But if we look just at silver plans, people who had the cheapest silver plan in the ND exchange in 2014 experienced an average rate increase of about 13 percent in 2015, assuming they didn’t make any plan changes. If they were willing to switch to the new cheapest silver plan however, their rate increase was much more muted, averaging just 4 percent.

And a Commonwealth Fund analysis in December 2014 found an average rate increase of 7 percent (for a 40-year-old non-smoker) across all plans and metal levels in the North Dakota exchange.

North Dakota’s 2014 enrollments

As of April 19, 2014, 10,597 people had enrolled in private plans through the North Dakota exchange. 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.

By of July 6, there were 9,953 enrolled through the exchange in North Dakota. That’s more than the state reported in mid-May (8,374), but lower than the total at the end of open enrollment because not everyone who enrolled ended up paying their premiums and keeping their new policies.

Enrollment is expected to be lower in sparsely-populated North Dakota. Despite the low figures, the state decreased its uninsured rate by two percentage points – from 15 percent to 13 percent – during the first half of 2014.

North Dakota Medicaid expansion

In addition to private plan enrollments, by early June 2014 nearly 9,000 low-income North Dakota residents had enrolled in the state’s expanded Medicaid program. North Dakota has followed a unique public-private partnership model of Medicaid expansion, allowing private health insurance carriers to bid for the opportunity to provide health insurance coverage to the state’s newly-eligible Medicaid population using federal Medicaid funds. Sanford and Blue Cross Blue Shield of ND placed bids, and ultimately Sanford accepted the job.

By October 2015, total enrollment in North Dakota’s Medicaid program had increased by 19,263 people since the end of 2013. That’s a growth of 28 percent, but it includes growth among both the newly-eligible population as well as people who were already eligible prior to 2014 but not enrolled.

Higher than average after-subsidy rates in 2014

A report released by HHS in June 2014 found that 84 percent of enrollees in the North Dakota exchange received premium subsidies, and the average after-subsidy premium in 2014 was $132 per month. This was the second-highest average after-subsidy premium out of the 36 states where HHS was running the exchange in 2014 (only New Jersey was higher, at $148 per month), and was considerably higher than the $82 per month average across all 36 states.

But the higher average net price in North Dakota was a function of enrollees’ incomes and the plans they selected, as the Obamacare premium tax credits do a very good job of evening out premiums across populations with similar household incomes. The average pre-subsidy premium in North Dakota was $350 per month, which is very close to the $346 average pre-subsidy premium across all 36 federally-facilitated marketplaces in 2014.

Grandmothered plans

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 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. In May 2014, he extended that allowance following the transitional relief extension issued by HHS in March (permits non-compliant coverage to be renewed until as late as October 2016, and remain in force until as late as September 2017).

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.

North Dakota exchange history

The North Dakota House of Representative voted against a state-run health insurance exchange in 2011, and 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 28 percent from the end of 2013 to October 2015.

North Dakota health insurance exchange links

State Exchange Profile: North DakotaThe Henry J. Kaiser Family Foundation overview of North Dakota’s progress toward creating a state health insurance exchange.

Get Covered North Dakota

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 /

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.