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Officials predict only 5% of North Dakota Medicaid recipients will be impacted by program changes • North Dakota Monitor [1]

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Date: 2025-08-06

North Dakota is well positioned to deal with changes to the Medicaid program, but the Department of Health and Human Services does expect 3% to 5% of the state’s Medicaid population to be impacted by new requirements.

Patient advocates worry that people eligible for Medicaid will lose coverage due to new administrative hurdles, and the loss of Affordable Care Act tax credits may cause further challenges.

North Dakota HHS estimates between 3,000 to 5,000 people who use the Medicaid expansion program will be impacted by new federal rules in coming years, said Sarah Aker, executive director of medical services for the North Dakota Department of Health and Human Services.

“While there will be changes to people’s experiences on Medicaid over the next couple of years as we implement the requirements, we hope they will be good additions to the program,” Aker said. “If people are compliant, if people meet the eligibility requirements, they will stay covered.”

Medicaid expansion was established in North Dakota in 2014 and covers people ages 19-64 who earn up to 138% the federal poverty level, or $21,597 for a single person or up to $44,367 for a family of four. As of June, the state had about 23,000 people enrolled in the Medicaid expansion program out of more than 108,000 total Medicaid enrollees.

Aker said one change stems from new work requirements for Medicaid expansion recipients included in the congressional budget reconciliation package. The new requirements mandate working-age adults between 19-64 years of age complete 80 hours of volunteering, education or work per month, and are set to begin in 2027.

Many people within the Medicaid expansion group are exempt from the new provisions, she added, including pregnant women, people who are medically frail, tribal members, parents and caretakers with children under 14 years of age, recipients with substance-use disorders or mental health conditions that prevent them from working, and cancer patients, among others.

“When you take out all of those exemptions, we think the impact is about 3% to 5% of the total Medicaid population, so a pretty small percentage of that 108,000,” Aker said.

Ben Hanson, North Dakota government relations director for the American Cancer Society Cancer Action Network, questions those numbers, pointing to the federal legislation that cuts a substantial portion of federal Medicaid spending.

“At some point, someone is going to get their health coverage taken away from them,” Hanson said.

Many North Dakota Medicaid recipients are already working, Hanson said. Some people who are part of the Medicaid expansion program are employed by small businesses in the state with under 20 employees that may not be able to offer group health insurance because of the cost, he said

The burden will also increase on those small employers to verify the employment status of their employees at a time when their workforce is already spread thin, he said.

“It’s another layer of paperwork or red tape that we hear so often is not good for business,” Hanson said.

Aker said the first major impact people will see from the changes to the Medicaid program will be during the first six-month eligibility renewal in July 2027.

Shannon Bacon, director of external affairs for the Community HealthCare Association of the Dakotas, said the nonprofit supports community health centers that serve rural, low-income and underserved people.

When states have tried adding work requirements or other steps to prove eligibility in the past, they’ve seen a lot of “procedural disenrollment,” she said. That occurs when someone is still eligible for the program but missed a deadline or were not able to submit the correct documentation to receive an exemption.

“That’s the thing that is going to be the most key during the implementation,” Bacon said.

In addition to the changes to the Medicaid program, Bacon said, Advanced Premium Tax Credits that are part of the Affordable Care Act marketplace are set to expire at the end of the year without congressional intervention.

“In North Dakota, a lot of people are benefiting and may not even realize it from these enhanced premium tax credits under marketplace,” Bacon said.

If those tax credits are not renewed, North Dakotans will pay an average of $485 more per month for health insurance through the ACA, according to KFF.

In 2024, more than 34,000 North Dakotans received Advanced Premium Tax Credits through the ACA marketplace, up from almost 31,000 in 2023.

Retroactive filing dates, also part of the new law, will affect all Medicaid recipients, Aker said.

Before the reconciliation bill was passed, anyone who signed up for Medicaid received a 90-day retroactive date for health care services they were provided, if they qualified for them at the time. That retroactive timeline will be reduced to two months for enrollees in the standard Medicaid program and one month for Medicaid expansion members under the new law.

Still, Aker said, national discussion about a lot of the changes “overstates” their impact on North Dakota.

“There’s a saying we have in Medicaid that if you’ve seen one state’s Medicaid program, you’ve seen one state’s Medicaid program,” Aker said. “And our choices have set us up well to be in compliance with the bill.”

This story was updated to correct the potential impact to North Dakota Medicaid recipients.

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[1] Url: https://northdakotamonitor.com/2025/08/06/officials-predict-only-5-of-north-dakota-medicaid-recipients-will-be-impacted-by-program-changes/

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