Division of Medical Services outlines Medicaid enrollment, costs, staffing rules and drug pressures

Division of Medical Services executive director Sarah Acre told the Appropriations - Human Resources Division committee that Medicaid provides coverage to roughly one in seven North Dakotans and that recent federal rule changes, high-cost prescription drugs and nursing-facility staffing requirements are major budget drivers.

Acre opened her presentation by noting the agency’s strategic goal: "we really like to have strategy drive our agency." She described Medicaid as "a healthcare coverage program" that in state fiscal year 2024 covered more than 150,000 unduplicated individuals and averaged about 112,000 enrollees per month, with children making up 46 percent of enrollees and expansion adults 25 percent.

Why it matters: Medicaid is one of the largest state-funded programs and pays for more than half of nursing facility residents. Acre told the committee that the program’s mix of enrollment and rising acuity — more enrollees with chronic and behavioral-health conditions — plus federal mandates and pharmacy costs, are increasing pressure on the state budget.

Acre reviewed program scope and rules. She said North Dakota operates both Medicaid and CHIP (as a Medicaid look-alike), maintains a state Medicaid plan and multiple 1915(c) Home-and-Community-Based Services (HCBS) waivers, and runs PACE (Programs of All‑Inclusive Care for the Elderly) in Minot, Bismarck, Dickinson and Fargo. She noted that waivers use both financial and functional eligibility, and that only an individual’s income is counted for waiver eligibility in many child waiver cases.

Enrollment and unwinding: Acre summarized the federal continuous-coverage period imposed during the pandemic and the subsequent "unwinding" of that policy. She said North Dakota’s enrollment peaked at roughly 37,684 eligible individuals during the COVID-era continuous coverage period and has since declined and…