If you live in North Dakota and need health insurance, the Affordable Care Act (ACA) marketplace provides access to comprehensive coverage with financial assistance that can significantly reduce your costs. North Dakota has expanded its benefits in recent years, adding coverage for insulin cost caps, hearing aids, weight loss medications, and nutritional counseling to all ACA marketplace plans starting in 2025.
This guide walks you through everything you need to know about North Dakota ACA benefits and coverage, from what every plan must include to how much help you can get paying for premiums.
How the ACA Marketplace Works in North Dakota
North Dakota uses the federal marketplace at Healthcare.gov to offer individual and family health insurance plans. Residents shop for coverage through this national platform rather than a state-run exchange.
Three insurance companies offer plans on the North Dakota marketplace:
- Blue Cross Blue Shield of North Dakota
- Sanford Health Plan
- Medica
All marketplace plans are ACA compliant, meaning they must cover the same set of essential health benefits and cannot deny you coverage or charge you more based on pre-existing conditions.
Open Enrollment Period
The annual open enrollment period for 2026 coverage runs from November 1 through January 15. During this window, you can sign up for a new plan, switch plans, or renew your existing coverage.
Outside of open enrollment, you may still qualify for a Special Enrollment Period (SEP) if you experience a qualifying life event such as:
- Losing existing health coverage
- Getting married or divorced
- Having or adopting a child
- Moving to a new area
- Turning 26 and aging off a parent's plan
- Changes in household income that affect Medicaid or subsidy eligibility
Essential Health Benefits Covered by North Dakota ACA Plans
Every ACA marketplace plan in North Dakota must cover 10 categories of essential health benefits (EHBs). These benefits are required regardless of which insurer or plan level you choose:
- Ambulatory patient services (outpatient care)
- Emergency services (emergency room visits)
- Hospitalization (inpatient care)
- Maternity and newborn care (prenatal visits, labor and delivery, postnatal care)
- Mental health and substance use disorder services (therapy, counseling, inpatient treatment)
- Prescription drugs
- Rehabilitative and habilitative services and devices (physical therapy, occupational therapy, speech therapy)
- Laboratory services (blood work, diagnostic testing)
- Preventive and wellness services and chronic disease management (annual checkups, immunizations, screenings)
- Pediatric services (dental and vision care for children)
All marketplace plans must also cover these benefits with no annual or lifetime dollar limits on coverage.
New Benefits Added for North Dakota ACA Plans
In 2023, the federal government approved North Dakota's application to update its essential health benefit benchmark plan. Starting with plans beginning January 1, 2025, the following additional benefits are included in all North Dakota ACA marketplace plans:
- Insulin and insulin supplies: Out-of-pocket costs are limited for a 30-day supply of covered insulin drugs and medical supplies for insulin dosing and administration
- Hearing aids: Coverage for one hearing aid per hearing-impaired ear every 36 months when deemed medically necessary by a licensed physician or audiologist
- Nutritional benefits: Coverage for dietary or nutritional screening, counseling, and therapy for obesity, diabetes, or chronic illness (up to 12 sessions per policy year when deemed medically necessary)
- Weight loss drugs: Coverage for GLP-1 and GIP drugs as therapy for prevention and treatment of qualifying conditions
These additions make North Dakota one of the more generous states in terms of what ACA marketplace plans must cover.
Plan Levels and What They Mean
ACA marketplace plans in North Dakota come in four metal tiers, plus catastrophic plans for those under 30 or who qualify for a hardship exemption:
| Plan Level | You Pay (Avg) | Insurer Pays (Avg) | Best For |
|---|---|---|---|
| Bronze | 40% | 60% | Low premiums, healthy individuals |
| Silver | 30% | 70% | Moderate costs, subsidy-eligible households |
| Gold | 20% | 80% | Frequent medical care |
| Platinum | 10% | 90% | High medical needs |
Silver plans are especially important if your income is between 100% and 250% of the federal poverty level (FPL). At this income range, you may qualify for Cost-Sharing Reductions (CSRs) that lower your deductibles, copays, and out-of-pocket maximums. CSRs are only available with Silver plans.
Income Limits for ACA Subsidies in North Dakota
Premium tax credits (also called subsidies) help lower your monthly insurance premiums. For the 2026 plan year, subsidies are available to households with incomes between 100% and 400% of the federal poverty level. Note that enhanced subsidies that were available from 2021 through 2025 have expired, meaning the "subsidy cliff" at 400% FPL has returned for 2026.
2026 ACA Subsidy Income Limits (Based on 2025 Federal Poverty Guidelines)
| Household Size | 100% FPL (Minimum) | 150% FPL | 250% FPL | 400% FPL (Maximum for Subsidies) |
|---|---|---|---|---|
| 1 | $15,650 | $23,475 | $39,125 | $62,600 |
| 2 | $21,150 | $31,725 | $52,875 | $84,600 |
| 3 | $26,650 | $39,975 | $66,625 | $106,600 |
| 4 | $32,150 | $48,225 | $80,375 | $128,600 |
| 5 | $37,650 | $56,475 | $94,125 | $150,600 |
| 6 | $43,150 | $64,725 | $107,875 | $172,600 |
Important notes about subsidy eligibility:
- If your income falls below 100% FPL, you likely qualify for North Dakota Medicaid instead
- If your income exceeds 400% FPL, you will not receive any premium tax credits for 2026
- Cost-Sharing Reductions are available for incomes between 100% and 250% FPL (Silver plans only)
- You must not have access to affordable employer-sponsored coverage or be eligible for Medicare
Not sure if you qualify? Check your eligibility with our free screening tool to see what programs you may be eligible for in minutes.
North Dakota Medicaid and the Coverage Connection
North Dakota expanded Medicaid under the ACA in 2014, which means adults ages 19 to 64 with household incomes up to 138% of the federal poverty level can qualify for Medicaid coverage at no cost or very low cost.
2026 North Dakota Medicaid Income Limits (138% FPL)
| Household Size | Annual Income Limit |
|---|---|
| 1 | $21,597 |
| 2 | $29,187 |
| 3 | $36,777 |
| 4 | $44,367 |
| 5 | $51,957 |
| 6 | $59,547 |
If your income is above the Medicaid limit but below 400% FPL, you will transition to ACA marketplace coverage with premium tax credits. North Dakota's Medicaid expansion means there is no "coverage gap" in the state. Every resident has a path to affordable health coverage, either through Medicaid or subsidized marketplace plans.
For more details on all available programs, visit our North Dakota Benefits Overview page.
How to Apply for ACA Coverage in North Dakota
Follow these steps to enroll in a North Dakota ACA marketplace plan:
Step 1: Gather Your Information
Before you start, collect the following for each household member who needs coverage:
- Social Security numbers
- Date of birth
- Current income information (pay stubs, tax returns, or W-2s)
- Information about any employer-sponsored coverage available to you
- Immigration documents (if applicable)
Step 2: Check Your Eligibility
Use our free benefits screening tool to see what programs you qualify for, including ACA subsidies, Medicaid, and other assistance programs.
Step 3: Create an Account on Healthcare.gov
Visit Healthcare.gov and create an account. You will need a valid email address and to set up a username and password.
Step 4: Complete Your Application
Fill out the marketplace application with your household, income, and coverage information. The application will determine:
- Whether you qualify for premium tax credits
- Whether you qualify for Cost-Sharing Reductions
- Whether you may be eligible for Medicaid instead
- Your estimated monthly premium after subsidies
Step 5: Compare Plans and Enroll
Review the plans available in your area from Blue Cross Blue Shield of North Dakota, Sanford Health Plan, and Medica. Compare monthly premiums, deductibles, copays, provider networks, and prescription drug coverage before selecting a plan.
Step 6: Pay Your First Premium
Your coverage does not begin until you pay your first monthly premium. Make sure to pay on time to activate your plan.
Getting Help With Enrollment
You do not have to navigate the process alone. North Dakota offers several free resources:
- Healthcare.gov helpline: Call 1-800-318-2596 (available 24/7)
- Local navigators and certified application counselors: Trained professionals who can walk you through the application at no cost
- Licensed insurance agents and brokers: Can help you compare plans and enroll (their services are free to you)
- Community Action Agencies: Many local organizations across North Dakota offer enrollment assistance
What to Know About 2026 ACA Changes
Several important changes affect North Dakota ACA coverage for 2026:
- Enhanced subsidies have expired: The American Rescue Plan and Inflation Reduction Act temporarily expanded premium tax credits through 2025. For 2026, the subsidy cliff at 400% FPL has returned, meaning households earning above that threshold will not receive premium assistance
- Rate increases: Average approved rate changes for 2026 include 8.3% for Blue Cross Blue Shield of North Dakota, 5.1% for Sanford Health Plan, and 23.1% for Medica
- Expanded catastrophic plan eligibility: Catastrophic plans have expanded eligibility criteria for 2026
- Full APTC repayment: Starting in 2026, there is no longer a cap on how much excess advance premium tax credit must be repaid at tax time, so report income changes promptly
Frequently Asked Questions
What does North Dakota ACA coverage include?
All ACA marketplace plans in North Dakota cover the 10 essential health benefits, plus additional state-mandated benefits including insulin cost caps, hearing aids, nutritional counseling, and weight loss medications. Preventive care services like annual checkups, vaccinations, and cancer screenings are covered at no cost to you.
How much does ACA health insurance cost in North Dakota?
Costs vary based on your age, location, income, household size, and the plan you choose. With premium tax credits, many North Dakota residents pay significantly less than the full premium price. Use our screening tool to get a personalized estimate.
Can I get ACA coverage if I have a pre-existing condition?
Yes. Under the ACA, insurance companies cannot deny you coverage, charge you higher premiums, or exclude coverage for pre-existing conditions. This applies to all marketplace plans in North Dakota.
What is the difference between Medicaid and ACA marketplace coverage in North Dakota?
Medicaid is a government health insurance program for individuals and families with incomes up to 138% FPL. It provides coverage at little to no cost. ACA marketplace plans are private insurance plans available to those with higher incomes who may receive premium tax credits to reduce their costs. North Dakota's Medicaid expansion ensures there is no gap between the two programs.
Can I enroll outside of open enrollment?
You can only enroll during the annual open enrollment period (November 1 to January 15) unless you qualify for a Special Enrollment Period triggered by a life event like losing coverage, getting married, having a baby, or moving.
What happens if my income changes during the year?
Report income changes to the marketplace as soon as possible. Your subsidy amount may be adjusted. For 2026, there is no cap on the amount of excess advance premium tax credits you may need to repay at tax time, so keeping your income estimate accurate is especially important.
Are dental and vision covered under North Dakota ACA plans?
Pediatric dental and vision care are covered as essential health benefits. Adult dental and vision coverage may be limited depending on the plan you choose. Some plans offer supplemental dental and vision options.
Take the Next Step
Finding affordable health coverage in North Dakota does not have to be complicated. Whether you qualify for Medicaid, subsidized marketplace coverage, or other assistance programs, help is available.
Check your eligibility now with our free screening tool to discover all the benefits you may qualify for in just a few minutes. You can also explore our North Dakota Benefits Overview for information on additional programs like SNAP, LIHEAP, and more.
