North Dakota and the ACA’s Medicaid expansion

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Medicaid expansion in North Dakota

North Dakota opted to expand Medicaid using federal funding, and estimated that up to 35,000 residents were newly eligible for expanded coverage starting in 2014. But as of September 2017, enrollment in North Dakota’s Medicaid expansion stood at fewer than 20,000 people. Medicaid expansion in North Dakota is provided via Sanford Health Plan’s Medicaid managed care program.

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.

Legislation enacted to extend Medicaid expansion to 2019

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 (ND1012) in 2017 that extends the program through July 2019.

Dalrymple, whose final budget proposal had 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.

Costs higher than expected

As has been the case in many states, the cost of expanding Medicaid has been 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 percent of the cost in 2017, and by 2020, the state will have to pay 10 percent 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

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 ended up getting the state contract. Residents who are eligible for expanded Medicaid can contact Sanford Health Plan with questions at [email protected] or call 855-305-5060 (Sanford member services). Sanford also created a

Residents who are eligible for expanded Medicaid can contact Sanford Health Plan with questions at [email protected] or call 855-305-5060 (Sanford member services). Sanford also created a compilation of FAQs about Medicaid expansion in the state.

Who is eligible for North Dakota Medicaid?

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 percent of poverty (income limits for various family sizes are here).
  • Children age 0 – 5 with household income up to 147 percent of poverty, and children 6 – 18 with household income up to 133 percent of poverty.
  • CHIP is available to children with household incomes up to 170 percent of poverty (about $40,545 for a family of four).  This is the lowest eligibility cap in the nation for CHIP, but families slightly above this threshold qualify for subsidies in the exchange.
  • Pregnant women with household income up to 147 percent of poverty.

How do I enroll?

Enrollment in Medicaid is year-round; you do not need to wait for an open enrollment period if you’re eligible for Medicaid

  • North Dakota uses the federally-run insurance marketplace, so you can enroll through HealthCare.gov or use their call center at 1-800-318-2596.
  • 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 County Social Services Office (click on your county to see contact information) for in-person or phone assistance with enrollment

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 HealthCare.gov, 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 percent, from 69,980 to 96,276 enrollees.

According to US Census data, the uninsured rate in North Dakota fell from 10.4 percent in 2013 to 7.9 percent in 2014; a 24 percent 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. And by 2016, the uninsured rate had dropped only slightly, to 7 percent.

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.


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.