Medicare in North Dakota

Medicare is a federal program that provides health insurance to people aged 65 and over, and younger people who have end-stage renal disease or certain disabilities. In 2020 more than 133,400 North Dakotans received health care through the program, compared to 120,700 beneficiaries in 2015. This equates to 17% of the state’s population. Out of all enrolled residents, 21% were enrolled in Medicare Advantage, half the national average of 42%. 

Medicare beneficiaries receive hospital, nursing home and some home health care through Medicare Part A. This is free to people who paid Medicare payroll taxes for a minimum number of years, as well as their spouses. Outpatient medical services including doctor’s office visits, mental health services and medical supplies are covered by Medicare Part B. The monthly premium for Part B is based on income and starts at $170.10 in 2022.

Together, Part A and Part B are referred to as Original Medicare. Seniors in Original Medicare don’t receive prescription drug coverage, but Medicare Part D plans can be purchased from private providers to help seniors access medications. 

Seniors can also choose to enroll in Medicare Advantage, also known as MA plan or Medicare Part C. This is an alternative to Original Medicare that’s offered by private insurers. All plans offered through this program are Medicare-compliant and, except for hospice care, must offer the same benefits as Original Medicare. These plans can also offer additional benefits such as dental, vision and hearing care, and generally include prescription drug coverage (Part D). Medicare Supplement Insurance, also known as Medigap, can also be purchased from private providers to help reduce out-of-pocket costs for Original Medicare policyholders.

This guide has information about Medicare in North Dakota, including options available to seniors and resources that can help them make the best insurance decision for their health care needs.

Options for Medicare Coverage in North Dakota

Original Medicare is a good choice for many older North Dakotans, but an increasing number of seniors are exploring options in Medicare Advantage and Medicare Supplement plans so they can find policies that better suit their needs for expanded services. In addition to regular Medicare administered by the federal government, Medicare Advantage and Medicare Supplement plans can be purchased from private health insurance companies, and plans vary depending on where those companies are located in various parts of the state. All MA plans are regulated by Medicare to ensure they offer adequate coverage for beneficiaries.

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage (MA) is an alternative to Original Medicare, It’s administered by private companies whose plans are regulated by the federal government. MA plans must contain Medicare Parts A and B, with the exception of hospice care which remains covered under Medicare Part A.

MA plans also have options for coverage beyond Original Medicare, like dental and vision care. Most MA providers offer prescription drug coverage (Part D), and some plans include wellness programs and transport to medical appointments. 

In 2021, just over 21% of Medicare-eligible North Dakotans are enrolled in Medicare Advantage. These seniors choose from six Medicare Advantage plan types. The four that are most popular are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs). Providers can set their own costs for premiums, copays and deductibles. Each plan also has different rules regarding referrals, primary care physicians and in-network providers.

Who Should Consider Medicare Advantage

Medicare Advantage can be a good choice for people who:

• Are comfortable with managed care
• Need additional benefits that are not covered by the Original Medicare
• Are generally healthy so may benefit from lower premiumsWant more control over out-of-pocket costs

The Top 10 Medicare Advantage Plans in North Dakota

There is a wide range of highly rated Medicare Advantage plans to choose from in North Dakota. The following table lists the 10 most popular providers in the state based on the total number of people enrolled. It also provides information about the types of available plans and the costs for beneficiaries as of April 2022. As each provider offers multiple plans, the costs are provided as a range rather than an average. For more information about Medicare Part C, seniors can visit this link to Medicare Advantage in North Dakota.

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2022 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in North Dakota

Many seniors find they need assistance to navigate Medicare’s enrollment process and the public and private health care options available to them. North Dakota has a number of resources that offer guidance to Medicare-eligible residents. The following resources have one-on-one counseling and other services that can help beneficiaries enroll in Medicare, understand benefits and find the best Original Medicare, Medicare Advantage or Medigap plan for their needs.