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North Dakota health insurance

Three insurers are offering 2019 coverage on the state's health marketplace through December 15.

Health insurance in North Dakota

North Dakota’s health insurance marketplace

North Dakota did not establish its own health insurance exchange, so it utilizes for enrollment.

The state’s open enrollment dates for 2019 coverage also follow states – running from November 1 through December 15, 2018.

2019 health insurance rates and carriers

In North Dakota’s individual market, there are three health insurance carriers. Prior to 2018, they all sold policies both on and off the exchange. But Medica exited the exchange market (and continued to sell plans off-exchange) at the end of 2017, because North Dakota regulators wouldn’t allow insurers to add the cost of cost-sharing reductions to premiums for 2018. (North Dakota, Vermont, and DC were the only states that took that approach.)

For 2019, however, North Dakota allowed insurers to add the cost of CSR to Silver plan premiums, so Medica rejoined the exchange. Medica had just 559 enrollees in 2018, but their membership is likely to increase again in 2019 when their plans are once again available on- and off-exchange.

For 2019 coverage in the North Dakota exchange, insurers proposed an average premium increase of 7.4 percent, although the approved rate changes ended up being smaller than the insurers had proposed. Because the state will start to allow insurers to add the cost of cost-sharing reductions (CSR) to Silver plan rates for 2019, average premium subsidies are significantly larger than they were in 2018.

For people who get premium subsidies, this will make Bronze and Gold plans more affordable than they were in 2018 and prior years.

Those carriers and their average approved rate increases are as follows:

  • Blue Cross Blue Shield of North Dakota – Average exchange plan increase: 2.29 percent
  • Medica – Average exchange plan rate increase: 25.99 percent.
  • Sanford – Average exchange plan rate increase: 21.53 percent

North Dakota’s Insurance Department conducted a study in the summer of 2018, considering ways to stabilize the state’s individual health insurance market. The results of the study were announced in September 2018, and the Department plans to propose legislation for lawmakers to consider in 2019, with the hope of implementing market stabilization provisions in 2020.

Specifically, the Department is proposing a state-based reinsurance program (already enacted by several other states) and state-based health plans that would be in the same risk pool with ACA-compliant plans but operate under different rules. Both proposals would require the approval of state lawmakers and the federal Department of Health and Human Services.

North Dakota enrollment in QHPs

In late 2013, shortly after open enrollment began, the Kaiser Family Foundation estimated the potential market for the exchange in North Dakota to be 77,000 residents. They also predicted that about 44,000 of them would qualify for premium subsidies.

North Dakota’s exchange is one of just a few where enrollment has climbed every year since 2014. But even so, enrollment during the open enrollment period for 2018 coverage only reached 22,486 people. Effectuated enrollment as of February 2018 stood at 20,940. Of those enrollees, 87 percent were receiving premium subsidies and 46 percent were receiving cost-sharing subsidies (CSR).

The average total per-person premium in North Dakota’s exchange in 2018 was about $452/month, which is significantly lower than the national average of $597/month. But for the 87 percent of North Dakota enrollees who receive premium subsidies, the average premium subsidy is almost $326/month, resulting in an after-subsidy premium of just $126/month.

When the cost of CSR is added to Silver plan rates for 2019, the premium subsidies (which are based on the cost of Silver plans) will grow disproportionately large, to offset the disproportionately high Silver plan rates. This will end up making Bronze and Gold plans relatively more affordable in 2019 than they have been in prior years.

Read more about the North Dakota health insurance exchange.

North Dakota Medicaid/CHIP enrollment

Accepting federal funds to expand Medicaid in North Dakota has been a key aspect of the law’s success there. All legal residents with incomes up to 138 percent of poverty are now eligible for Medicaid. With North Dakota Medicaid expansion underway in 2014, there were 35,000 people estimated to be newly eligible for coverage.

But as of September 2017, enrollment in Medicaid expansion in North Dakota was still under 20,000 people.

As of May 2018, North Dakota’s monthly average Medicaid/CHIP enrollment had grown 38 percent, reaching 96,276. That was a growth of about 26,000 people since 2013. But some of those individuals were already eligible, but not enrolled, pre-2013 (so they don’t count as being in the Medicaid expansion population), and some are enrolled in CHIP. (Eligibility guidelines have not changed under the ACA for CHIP.)

Enrollment in Medicaid continues year-round. The initial legislation to expand Medicaid under the ACA was slated to expire in July 2017, but the state enacted legislation in 2017 to extend that sunset date through July 2019.

Read more about Medicaid in North Dakota.

Short-term health insurance in North Dakota

North Dakota regulations limit short-term health insurance plan durations to 185 days. The regulations allow one non-underwritten renewal, so plan duration can be a total of 12 months.

Learn more about short-term health insurance in North Dakota.

ND health ratings

In 2018, the Commonwealth Fund’s Scorecard on State Health System Performance rated North Dakota 22nd out of the 50 states and District of Columbia. While the state excelled in the category of Avoidable Hospital Use & Costs (9th place), it was much more middle-of-the road for the other categories that the Scorecard measures.

North Dakota’s Scorecard includes additional details about the state’s health factors and outcomes to show how the rankings are calculated.

But the 2017 edition of America’s Health Rankings placed North Dakota slightly higher, at 18th place — although this was a drop of seven spots since the 2016 ranking, with North Dakota dropping more than any other state. The state tops the charts in terms of having the lowest incidence of frequent physical and mental distress among residents, but ranks 49th for excessive drinking and 37th for the percentage of children under 35 months who had received their recommended vaccinations.

Trust for America’s Health has summarized additional information on the state’s specific disease incidence and health factors for adults and children. The details are in the 2016 listing of Key Health Data About North Dakota.

You can also view North Dakota health data on a county level with this interactive map showing the counties in North Dakota based on their public health outcomes and health factors. High- and low-ranking counties are well dispersed in the state, with no single region clearly outperforming the others.

How has the ACA helped North Dakota?

At the end of 2013, there were about 70,000 uninsured residents in North Dakota. Thanks in large part to the ACA and the state’s acceptance of Medicaid expansion, 39 percent of them became eligible for Medicaid. Another 31 percent were eligible for subsidies in the exchange.

The percentage of uninsured residents dropped from 10.4 percent in 2013 to 7 percent in 2016, according to US Census data. The national uninsured rate fell from 14.5 percent to 8.6 percent in the same time period. As of 2016, there were 21 states with uninsured rates below North Dakota’s.

North Dakota and the Affordable Care Act

In 2010, both of North Dakota’s U.S. Senators, Democrats Kent Conrad and Byron Dorgan, were supportive of the health reform law. In the House, the Earl Pomeroy, a Democrat, and the lone representative from North Dakota, also voted yes.

The entire congressional delegation from North Dakota has changed since 2010, however, and now includes one Democratic senator and one Republican, as well as a Republican representative. Sen. Heidi Heitkamp is supportive of the law, but would like to see some improvements added to it.

Sen. John Hoeven, a Republican and the former governor, is opposed to the ACA but was one of the 23 Republicans who joined with Democrats in voting to end the debate in 2013 on a resolution that would have defunded Obamacare. However, Hoeven voted yes on all three ACA repeal measures that were considered in the Senate during the summer of 2017.

Rep. Kevin Cramer, a Republican, is opposed to the ACA and would prefer to see it repealed and replaced with a market-driven solution. He won re-election in November 2014. When the House passed the American Health Care Act (AHCA) to repeal parts of the ACA in 2017, there were 20 Republican representatives who voted no. Cramer was not among them — he supported the House GOP efforts to roll back the ACA using budget reconciliation (that measure ultimately did not advance, as all of the versions failed in the Senate).

At the state level, Republicans hold the majority in both the House and Senate. Former Gov. Jack Dalrymple, a Republican, stated that he was opposed to the ACA, but he was not an obstructionist about the law the way many other Republican governors have been. In 2013, Dalrymple said, “It’s not going to help to throw a bunch of roadblocks in front of this thing [the ACA] and have it fail. That’s not the responsible thing to do.”

In the spring of 2013, Dalrymple signed a bill to expand Medicaid in the state, allowing all legal residents with incomes up to 138 percent of poverty to be eligible for Medicaid benefits starting in 2014. The state opted for a federally facilitated marketplace however, and HHS is running the exchange in North Dakota.

Doug Burgum has been the governor of North Dakota since December 2016. In late 2017, he joined with 19 other Republican governors in writing a letter to Congress, urging lawmakers to repeal the ACA.

Does North Dakota have a high-risk pool?

Before the ACA brought guaranteed issue health insurance to the individual market, medical history was used to determine eligibility to purchase coverage in North Dakota, as it was in nearly every state. Pre-existing conditions could prevent an applicant from getting a policy at all, or could result in significant initial rate increases or policy exclusions.

The Comprehensive Health Association of North Dakota (CHAND) was created in 1981 to provide an alternative for residents who were unable to purchase individual private health insurance because of their medical history. The plan is administered by Blue Cross Blue Shield of North Dakota.

Now that Obamacare is in effect and all health insurance plans are guaranteed issue, risk pools are not needed the way they were prior to 2014. But CHAND is one of a few state-run pools that is still operational and still accepts new members if they meet the eligibility guidelines. In April 2015, then-Gov. Dalrymple signed SB 2231 into law. If HHS determines that CHAND coverage does not meet minimum essential coverage requirements under the ACA, SB 2231 gives the CHAND board the ability to modify the benefits in order to make the plan qualify as minimum essential coverage.

North Dakota Medicare enrollment

In 2015, Medicare enrollment reached 118,883 in North Dakota – that’s nearly 16 percent of the state’s population and just below the national average of 17 percent.

Historically, 85 percent of North Dakota Medicare recipients have qualified for coverage based on age alone, while 15 percent are on Medicare as the result of a disability.

Medicare pays about $7,821 per North Dakota enrollee each year. In terms of overall annual Medicare spending, the state ranks 48th with $859 million, as of 2009.

North Dakotans can select a Medicare Advantage plan instead of original Medicare if they wish to gain some additional benefits beyond what traditional coverage offers. About 18 percent of North Dakota Medicare recipients are enrolled in a Medicare Advantage plan, while 33 percent of all Medicare beneficiaries nationwide have made that selection.

Medicare Part D plans are also an option for those who want to stand-alone prescription drug coverage. North Dakota far exceeds the national average (44 percent) when it comes to Medicare Part D enrollment; 67 percent of North Dakota Medicare recipients have Part D plans. This makes sense, given that Original Medicare (as opposed to Medicare Advantage) is more popular in North Dakota than in many other states. Stand-alone Medicare Part D plans are designed to work with Original Medicare, as most Medicare Advantage plans already have their own integrated Part D coverage.

Helpful North Dakota health insurance links

State-based health reform legislation

Here’s a summary of recent North Dakota bills related to public health and healthcare reform (note that there are no legislative sessions in North Dakota in even-numbered years):