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North Dakota Medicaid and the new work rules
Medicaid Expansion is run by North Dakota Health and Human Services (ND HHS), Medical Services Division, which handles eligibility, applications and renewals through its Customer Support Center and the human service zone offices — but the expansion coverage itself is administered under contract by Blue Cross Blue Shield of North Dakota, which holds its own provider network and issues its own card. An expansion member therefore carries two cards rather than one: the BCBSND card for visits to a provider, and a separate ND Medicaid card for picking up prescriptions, because state law carves pharmacy out of the carrier arrangement. The catch worth knowing before you book anything is that a provider in BCBSND's ordinary commercial network is not automatically in its Medicaid Expansion network — joining that network takes a separate contract addendum — so check any provider with the Find a Doctor tool at medicaid.bcbsnd.com, or call BCBSND on 1-833-777-5779. North Dakota expanded Medicaid on January 1, 2014, which is why the new federal work requirement reaches this state — and why what you do before January 1, 2027 matters.
From January 1, 2027, most adults have to show 80 hours a month
The requirement applies to adults aged 19 to 64 covered through Medicaid expansion — around 23,000 people in North Dakota. It is not only about paid work: study, job training, volunteering and a mix of them all count , and earning at least $580 a month satisfies it on its own.
North Dakota checks first and asks second. The state says most members will not need to do anything extra, because it will use data sources it already holds to see whether a member meets the requirement; if it can verify that, it sends an approval notice and nothing more is required. If it cannot, it sends a notice listing exactly what it needs, and that information has to reach the Customer Support Center within 30 days of the date on the notice. Miss it and you may be denied or lose coverage. Proof can go back through the Self-Service Portal, by email to applyforhelp@nd.gov, by post to PO Box 5562, Bismarck ND 58506, or in person at a human service zone office.
If your hours swing from month to month, say so. The rule is written per month, which is the wrong shape for farm and fishing work, construction, tourism and seasonal retail — a good month and a dead month average out to a living, but the dead month is the one that fails. Federal law has a provision for exactly this: a seasonal worker can satisfy the requirement using their average monthly income over the previous six months instead of hours worked in the month being checked. It is at 42 CFR 435.552(a)(7), and the law defines who counts as seasonal by pointing at the tax code rather than listing jobs, so do not decide for yourself that it misses you. If your work is seasonal or your hours are irregular, tell the state that when you report, and ask for the six-month average to be used.
You do not have to prove anything if any of these describe you
Exemptions are meant to be applied by the state automatically from records it already holds, but records are imperfect. If one of these fits you and you still get asked to report hours, say so and ask them to check — don't assume the notice is right.
What you can earn and still qualify
Monthly income, before tax, for the whole household. These are the state's own published figures, which is what its caseworkers actually apply. If you are close to a line, apply anyway — some income does not count, and only the agency can run the calculation for your situation.
Adults 19 to 64138% of the poverty line
- 1 person
- $1,836
- 2 people
- $2,489
- 3 people
- $3,142
- 4 people
- $3,795
- 5 people
- $4,449
- 6 people
- $5,102
- 7 people
- $5,755
- 8 people
- $6,408
Pregnant175% of the poverty line
- 1 person
- $2,328
- 2 people
- $3,156
- 3 people
- $3,985
- 4 people
- $4,813
- 5 people
- $5,641
- 6 people
- $6,470
- 7 people
- $7,298
- 8 people
- $8,126
Source: North Dakota HHS published income levels effective April 1, 2026, from the Medicaid eligibility page at hhs.nd.gov and the ACA Medicaid Policy Manual release 26.3, read alongside the Non-ACA Medicaid Policy Manual section 510-05-85-40, revised July 1, 2026 (release 26.5). A note on precision: North Dakota rebuilds every income table on April 1 each year, so the Workers with Disabilities limit for a household of one is $2,993 a month under the April 1, 2026 table now in force and was $2,935 under the April 1, 2025 table that preceded it. We publish the state figure.
Two other changes land on the same day
Renewals get more frequent, and back-dated coverage gets shorter.
P.L. 119-21 §71112, amending 42 U.S.C. §1396a(a)(34). Applies to applications submitted on or after January 1, 2027.
North Dakota has a law that would end expansion automatically
Coverage here is tied by statute to how much the federal government pays.
Who this reaches. The law covers adults 19 through 64 covered through Medicaid Expansion — roughly 23,000 North Dakotans as of July 2026, all of whom hold their coverage through the BCBSND contract rather than through state fee-for-service Medicaid.
N.D. Cent. Code 50-24.1-37, whose official heading reads "Medicaid expansion - Legislative management report (Contingent repeal - See note)". North Dakota's expansion statute is written so that it can switch off, and it tells the department to warn people about that in advance. Subsection 1 is the mandate: the department "shall expand medical assistance coverage" under the Affordable Care Act to people under 65 with income below 138% of the federal poverty line. Subsection 2 is the warning: the department "shall inform new enrollees in the medical assistance expansion program that benefits may be reduced or eliminated if federal participation decreases or is eliminated." And the section's own heading records that it is subject to a contingent repeal. So the risk is not hypothetical drafting — it is a duty to tell every new enrollee that this coverage depends on continued federal funding.
What North Dakota has is a contingent repeal rather than a dated sunset, and it sits one layer away from the coverage itself. The same section that orders the expansion also carries the repeal condition, so if that condition is ever met the statutory instruction to cover this group goes with it. The practical exposure is wider than the statute, though: because expansion here is delivered under a procured contract with a commercial carrier, continuing it depends on the Legislative Assembly appropriating the money for that contract every two years as well as on the statute surviving. Subsection 4 requires the department to report to the legislative management on provider reimbursement rates under the expansion program before August 1 of each even-numbered year, which is the regular occasion on which the program comes back under legislative scrutiny.
Unexercised. Expansion has run without interruption since January 1, 2014 and no North Dakotan has lost coverage through this provision. Two things about the current text are worth stating precisely, because older accounts of this statute are still in circulation. There is no fixed sunset date in it any more: the 2013 Act that created the section expired section 1 "through July 31, 2017," that date is gone, and the codified text now runs on without one, with expansion funded through ordinary biennial appropriations. And the condition that would actually trigger the repeal is carried in a note to the section rather than in the section's own words — the note is not reproduced in the chapter text the Legislative Branch publishes, so this page states that the contingent repeal exists without putting words in its mouth. The last amendment to the section was by the 2023 Legislative Assembly, Session Laws chapter 416, which reached subsection 5, the provision making provider and managed care organization reimbursement rate information an open record. That was a change about rate information, not about a sunset date.
Nothing has changed, and this is not a reason to delay applying. It is a reason to keep your contact details current, open everything the state sends, and not assume coverage renews itself.
Do this now
Update your address and phone number first. Everything about the new rules arrives by mail, and a stale address is the most common reason people lose coverage they are still entitled to. Then check whether an exemption applies to you.
About the phone numbers: The two main numbers do different jobs, and in North Dakota that split is sharper than in most states. Call the state on 1-866-614-6005 for anything about eligibility, a renewal, a review you have been sent, an address change, or sending in proof of work hours. Call BCBSND on 1-833-777-5779 for anything about the coverage itself — what is covered, what you owe, and whether a provider is in the Medicaid Expansion network. Two numbers that look like the obvious ones are not. 1-800-755-2604 reaches the Medical Services Division and doubles as the fraud-reporting line rather than a member help line, and 701-328-2310 is the main ND HHS switchboard printed in the footer of every page, not a Medicaid line.
Deaf, hard of hearing or speech-impaired: 711.
Free interpreter line: 1-866-614-6005.
North Dakota's promise is interpreters rather than translated paperwork, and it is a broad promise. ND Medicaid says that if you need a free interpreter for its notices, for documents on its website, for covered services or for any other ND Medicaid information, you should contact the Customer Support Center on 1-866-614-6005, or 711 for TTY, Monday to Friday between 8am and 5pm Central. The Stay Enrolled page repeats it in three words — "Free translation is available" — next to the same number. Interpreters cost you nothing, and that holds whether you call, visit a human service zone office, or are reading a letter you do not understand. Spanish is the one language with a real set of translated documents: the Application for Assistance, form SFN 405, and its guidebook both exist in Spanish, and the notice attached to the appeals page does too. Beyond Spanish, the materials North Dakota publishes for understanding your coverage — the federal Coverage to Care set — come in Arabic, Chinese, Haitian Creole, Korean, Russian, Ukrainian and Vietnamese as well as English and Spanish, and there is a Tribal version alongside them. If your language is on that list, ask for the written material. If it is not, ask anyway, because the interpreter promise is not limited to the languages on any list. N.D. Cent. Code 50-24.1-44 gives interpreter services their own place in the Medicaid statute.
Most people who lose coverage lose it over paperwork, not eligibility
62% of the coverage losses recorded in North Dakota were procedural — a form, a deadline, or an address, rather than a real change in whether someone qualified. From January 1, 2027 that matters more, not less.
NOTICE OF ELIGIBILITY DETERMINATION
Case number: ███████
Date of this notice: 1January 12, 2027
Our records do not show that you met the community engagement requirement for the reporting period.
2If you believe this is incorrect, or if an exemption applies to you, contact us on or before February 11, 2027.
3Coverage for other members of your household is not affected by this notice.
What the federal data says about coverage here
Public federal data describes how each state runs its program. Almost all of it is written for policy analysts. Here is what those numbers mean if you are the person enrolled.
Of people who lost coverage here, this share lost it over paperwork rather than eligibility.
Open every letter. Keep your address current with the agency.
Provider supply here is around the national middle.
Book an appointment before you need one, not when you do.
Coverage here runs through private health plans rather than the state paying providers directly. You pick a plan, and your plan decides your network.
Check your doctor is in the plan before you choose it.
Where you live in this state changes what coverage is worth. North Dakota's access problem is not a shortage of clinicians per head — it is distance. The state actually ranks 7th in the country for primary care providers per 100,000 people, at 352.0 against a national 291.4, on America's Health Rankings' 2025 report. And yet HRSA's quarterly shortage summary for September 30, 2026 records 95 primary care shortage-area designations in North Dakota covering 202,041 people, with only 37.53% of the area's need met, and 44 of those designations are whole geographic areas rather than particular facilities or population groups. For mental health the designated population is 464,452 — more than half the state. 36 of North Dakota's 53 counties meet the "frontier" test of six or fewer people per square mile, about 39% of the population lives in a rural area, and 36 of the state's hospitals are Critical Access Hospitals, the designation for small rural facilities. March of Dimes classes 73.6% of North Dakota counties as maternity care deserts, meaning no hospital or birth centre offering obstetric care and no obstetric clinician at all. The distances that follow from this are ordinary here rather than exceptional: a cardiac patient treated at Valley City can be flown the 60 miles to Fargo for catheterisation, and the state's own cardiac and stroke systems coordinator has noted that about half of stroke patients reach a critical access hospital by private vehicle rather than by ambulance. It is also why so much of the marketplace here is rural — 25,971 of North Dakota's 41,014 marketplace enrollees for 2026, nearly two in three. For the new work rules the practical consequence is about paperwork rather than medicine: a member who has to document hours, or get a clinician to confirm a health condition, may be doing it a long way from the nearest office or clinic, which is why keeping an address current and answering a letter inside 30 days matters more here than in a dense state. HRSA Bureau of Health Workforce, Designated HPSA Quarterly Summary, fourth quarter of fiscal year 2026, as of September 30, 2026 (tables 3, 4 and 5); America's Health Rankings 2025 Annual Report, primary care providers measure, from CMS NPPES September 2025; ND HHS Primary Care Office shortage designations and its Primary Care Office Needs Assessment for the frontier-county count; UND Center for Rural Health, North Dakota hospitals; March of Dimes PeriStats, North Dakota, updated April 2025; CMS 2026 Marketplace Open Enrollment Period state-level public use file
You are exempt from the work requirement — and enrolling still matters
Five federally recognized tribes are located at least partly within North Dakota, and the state's own tribal-governments page names them as the Mandan, Hidatsa and Arikara Nation, also known as the Three Affiliated Tribes; the Spirit Lake Nation; the Standing Rock Sioux Tribe, whose reservation spans the North Dakota and South Dakota line; the Turtle Mountain Band of Chippewa Indians; and the Sisseton-Wahpeton Oyate Nation. The same page records one further Indian community in the state alongside those five. North Dakota sits in the Indian Health Service's Great Plains Area, which runs the Standing Rock Service Unit and its 12-bed Fort Yates Hospital with a round-the-clock emergency department, the Turtle Mountain Service Unit and its 27-bed Quentin N. Burdick Memorial Health Care Facility at Belcourt, the Spirit Lake Service Unit, the non-reservation Trenton Service Unit, and the Elbowoods Memorial Health Center. North Dakota Medicaid also facilitates care coordination agreements between health care providers and tribal health organizations under N.D. Cent. Code 50-24.1-40, which are the arrangements that draw full federal funding for care given to an American Indian. On the new rules, two protections matter and North Dakota publishes both. Native Americans and Alaska Natives are excluded from the work requirement outright — ND HHS lists them among the groups the new federal rules do not apply to. And tribal members are also excluded from the move to six-month redeterminations: the state's Stay Enrolled page says they "will still have an annual redetermination." So a tribal member in the expansion group faces neither of the two changes that reach everybody else in it. How the exclusion is established is worth understanding, because it is not a form you fill in each year. The federal rule puts the exclusion at 42 CFR 435.554(c)(2) and borrows the definition of "Indian" already used at 42 CFR 447.51 for Medicaid cost-sharing protections, precisely so that states can work from data they already hold; CMS states that a state will not be required to, and may not, reverify someone's status as an American Indian for this purpose, so once it is established it stays established. The practical step is to make sure the state actually knows: if you did not identify as American Indian or Alaska Native when you first applied, tell the Customer Support Center on 1-866-614-6005 so the exclusion is applied to your case rather than assume it has been. One North Dakota-specific question is not answered in the state's published materials, and it is worth asking rather than guessing: because expansion coverage here runs through the BCBSND network, nothing ND HHS publishes says whether an American Indian or Alaska Native expansion member can step outside that network to use an Indian Health Service or tribally operated facility, so call BCBSND on 1-833-777-5779 and ask before relying on it. Separately, members of federally recognized tribes do not pay the one-time $100 enrollment fee for the Workers with Disabilities buy-in.
Questions people ask about this
Do the new Medicaid work rules apply to me in North Dakota?
How many hours a month do I have to work?
Who is exempt from the work requirement in North Dakota?
When do the North Dakota work rules start?
What is the income limit for North Dakota Medicaid?
How do I apply for Medicaid Expansion?
How often do I have to renew North Dakota Medicaid?
Guides for neighboring states
The rules change completely at the state line. If you moved recently, or you're helping family somewhere else, start with their state rather than this one.
The date that matters for the new work rules in North Dakota is not January 1 but your own review — the state says the requirement begins for Medicaid Expansion members who have a review due on February 28, 2027, and for new applicants from January 1, 2027.
The other thing to get right is that your coverage is administered by Blue Cross Blue Shield of North Dakota, which changes who you call and which providers you can use. You hold two cards for one coverage: the BCBSND card for visits to a provider and a separate ND Medicaid card for picking up prescriptions, so keep both. Before you book anything, check that the provider is in the Medicaid Expansion network specifically, using the Find a Doctor tool at medicaid.bcbsnd.com or by calling BCBSND on 1-833-777-5779 — being in BCBSND's ordinary commercial network is not the same thing, because a provider already contracted with BCBSND has to sign a separate addendum to join the Medicaid Expansion network. For anything about eligibility, a renewal, or your address, the state is still the right call: the Customer Support Center on 1-866-614-6005, or the Self-Service Portal at applyforhelp.nd.gov. Keeping the address and phone number there current is the single most useful thing you can do before 2027, because North Dakota checks its own records first and then writes to you about whatever it cannot verify, and you get 30 days from the date on that letter to answer.
Updating your address takes two minutes and protects everything else. Do that first, then check the exemption list above.
Go to the Self-Service Portal at applyforhelp.nd.gov →