Long-Term Care Planning in North Dakota: Costs, Medicaid & Your Options (2026 Guide)

North Dakota's long-term care costs present a mixed picture — nursing home care averages $11,528 per month, approximately 20% above the national average of $9,581, while assisted living averages $4,729 per month, approximately 24% below the national average of $6,200. Home care averages $6,483 per month, roughly in line with the national rate of $6,673. North Dakota Medicaid is administered by the Department of Human Services (DHS). Uniquely, North Dakota has no set income limit for Nursing Home Medicaid — nearly all income must be paid towards care costs. The asset limit is $3,000 for individuals — higher than the $2,000 standard in most states. North Dakota uses a Medically Needy / Spend-Down program for applicants over the income limit — not Miller Trusts. This guide covers what care costs in North Dakota, how to qualify for Medicaid, and what options exist for veterans and family caregivers in Fargo, Bismarck, Grand Forks, Minot, and across the Peace Garden State.

North Dakota's Aging Population: The Numbers Behind the Need

North Dakota is home to approximately 130,000 residents aged 60 or older — a significant portion of the state's roughly 780,000 total population. The senior population is concentrated in Fargo (Cass County — ND's largest city), Bismarck (Burleigh County — the state capital), Grand Forks (Grand Forks County), Minot (Ward County), and West Fargo (Cass County). Other communities with notable senior populations include Mandan, Dickinson, Williston, Jamestown, and Devils Lake.

North Dakota's geography — a vast, largely rural state with population concentrated in a few cities — creates significant long-term care challenges. Fargo, Bismarck, Grand Forks, and Minot have the most facility options, while rural communities across western and central North Dakota, including Native American reservations, have far fewer providers and limited home care availability. Distance to care is a defining factor for many North Dakota families.

Unpaid Caregivers in North Dakota: Scale and Impact

An estimated 65,000 unpaid family caregivers in North Dakota provide care to aging relatives and adults with disabilities. According to AARP research, family caregivers nationwide spend an average of $7,242 per year in out-of-pocket costs related to caregiving.

North Dakota offers support for family caregivers through Medicaid State Plan Personal Care Services (MSP-PC), which allows program participants to choose their own Qualified Service Provider (QSP). Friends and select relatives can become a QSP and be hired to provide care. This makes North Dakota one of the states where Medicaid-funded family caregiver compensation is available.

What Long-Term Care Costs in North Dakota

North Dakota's care costs vary significantly by type of care:

• Assisted Living: $4,729 per month — approximately 24% below the national average of $6,200
• Nursing Home (semi-private room): $11,528 per month — approximately 20% above the national average of $9,581
• Home Care (home health aide): $6,483 per month — approximately 3% below the national average of $6,673
• Adult Day Care: $5,525 per month — approximately 168% above the national average of $2,058

At these rates, a three-year nursing home stay in North Dakota costs approximately $415,000 — while home care totals roughly $233,000 over the same period. Assisted living, at $4,729/month, totals approximately $170,000 over three years. For a detailed breakdown of care costs by type and how North Dakota compares to other states, visit our North Dakota Care Costs page.

How to Qualify for North Dakota Medicaid: Eligibility Rules for 2026

North Dakota Medicaid is administered by the Department of Human Services (DHS). In addition to nursing home care, ND Medicaid pays for services in adult foster care homes, assisted living facilities, and non-medical supports to help frail seniors live at home. Consulting with a North Dakota elder law attorney or Certified Medicaid Planner early can help families avoid costly mistakes. Eligibility rules vary by program type:

• Nursing Home Medicaid (Institutional): There is no set income limit — nearly all of a beneficiary's monthly income, minus a $115/month Personal Needs Allowance ($230/month for a married couple with both spouses as Medicaid recipients), Medicare premiums, and potentially a Needs Allowance for a non-applicant spouse, must be paid to the nursing home (Patient Liability). Asset limit of $3,000 (single) or $6,000 (couple, both applying). When only one spouse applies, the non-applicant spouse may retain up to $162,660 in assets. This is an entitlement.
• Medicaid Waivers / Home and Community Based Services (HCBS): Income limit of $1,174/month (single, eff. 4/1/25 – 3/31/26) or $1,587/month (couple). Asset limit of $3,000 (single) or $6,000 (couple, both applying). This is not an entitlement — waiting lists may exist.
• Regular Medicaid / Aged, Blind, Disabled: Income limit of $1,174/month (single) or $1,587/month (couple). Asset limit of $3,000 (single) or $6,000 (couple). This is an entitlement.

North Dakota applies a 60-month (5-year) look-back period for Nursing Home Medicaid and HCBS Waiver applications. Asset transfers during this period — including gifts to family members — can trigger a penalty period of Medicaid ineligibility. The federal $19,000 Gift Tax exclusion (2026) does NOT apply to Medicaid's look-back rules. The Look-Back Period does not apply to Regular Medicaid. For the full North Dakota Medicaid eligibility breakdown, see our North Dakota Medicaid Guide.

Spousal Protections and Community Spouse Resource Allowance

When one spouse applies for Institutional Medicaid or an HCBS Waiver in North Dakota, only the applicant spouse's income is counted. The Community Spouse Resource Allowance (CSRA) allows the non-applicant spouse to retain 50% of the couple's assets, up to $162,660 (2026). If the non-applicant's share falls below $32,532, up to $32,532 can be retained.

North Dakota sets the Minimum Monthly Needs Allowance (MMNA) at $2,644 per month (eff. 7/1/25 – 6/30/26). If the non-applicant spouse's income falls below this amount, income can be transferred from the applicant spouse. A non-applicant spouse with income of $2,644/month or more is not entitled to a Spousal Income Allowance. For Regular Medicaid, both spouses' income is counted and there is no MMNA or CSRA.

North Dakota Medicaid Programs: Personal Care, Waivers & Community Options

North Dakota offers Medicaid-funded long-term care programs:

• Medicaid State Plan Personal Care Services (MSP-PC): An entitlement program providing assistance with daily living activities including personal hygiene, mobility, shopping for essentials, meal preparation, and medication management. Participants must receive care from a Qualified Service Provider (QSP) but can choose their QSP. Friends and select relatives can become a QSP and be hired to provide care.
• Aged and Disabled Waiver: Also called the Medicaid Waiver for HCBS. Provides assistance to seniors and adults with disabilities, including personal care assistance, adult day care, home modifications, emergency response systems, meal delivery, and specialized medical equipment. Waiting lists may exist.
• Program of All-Inclusive Care for the Elderly (PACE): Combines Medicaid and Medicare benefits into a single program. Additional benefits such as dental and eye care may be available.
• Money Follows the Person: A federal program that helps institutionalized Medicaid-eligible persons transition back home or into the community.

Qualifying When Over the Limits: Medically Needy Spenddown

North Dakota does not use Qualified Income Trusts (Miller Trusts). The Medically Needy / Spend-Down program is available for persons over the income limit:

• Medically Needy / Spend-Down: The MNIL is $1,174/month (individual) and $1,587/month (couple) (eff. 4/1/25). The "client share" or "recipient liability" is the difference between income and the MNIL. Medical expenses — health insurance costs, Medicare premiums, transportation for medical care, medical service bills — can be used. Once the client share is met, one is Medicaid-eligible for the remainder of the month. The medically needy asset limit is $3,000 (individual) and $6,000 (couple).
• Asset Spend-Down: Spend excess assets on non-countable items — home modifications (wheelchair ramps, stair lifts), prepaying funeral/burial expenses, and paying off debt. Keep documentation as proof Medicaid's look-back rule was not violated.
• Medicaid Planning: Work with a Medicaid Planning Professional to employ legal strategies for eligibility and protect your home from Medicaid's Estate Recovery Program.

Notably, Nursing Home Medicaid has no set income limit — nearly all income goes towards care costs as a Patient Liability, making the income threshold less of a barrier for nursing home applicants compared to HCBS/Regular Medicaid.

Asset Rules: What Counts and What Doesn't

Countable assets in North Dakota include cash, stocks, bonds, investments, cryptocurrency, bank accounts (money market, savings, checking), and real estate in which one does not reside. In North Dakota, IRAs and 401Ks are exempt if in "payout status" — meaning one's Required Minimum Distribution (RMD) is being withdrawn, and the remaining balance does not count as an asset. Non-countable (exempt) assets include personal belongings, household furnishings, an automobile, irrevocable itemized burial contracts, and generally one's primary home.

North Dakota's asset limit is $3,000 for an individual and $6,000 for a married couple (both applying) — higher than the $2,000 standard used in most states. All assets of a married couple are considered jointly owned regardless of the Medicaid program. The CSRA allows the non-applicant spouse to retain 50% of assets up to $162,660 (minimum $32,532). There is no CSRA for Regular Medicaid. In North Dakota, VA Aid and Attendance and Housebound benefits do not count as income. Nationally, Holocaust restitution payments are not counted as income.

Veterans and Long-Term Care in North Dakota

North Dakota has a significant veteran population relative to its size, with facilities including the Fargo VA Health Care System, community-based outpatient clinics in Bismarck, Grand Forks, Minot, and other locations, and the North Dakota Veterans Home in Lisbon.

North Dakota does not count VA Aid and Attendance or Housebound benefits as income for Medicaid eligibility purposes. Veterans should factor this advantage into their long-term care planning strategy. For a comprehensive overview of veteran long-term care benefits, see our Veterans Long-Term Care Guide.

Planning Ahead: How to Pay for Nursing Home Care in North Dakota

Understanding how to pay for nursing home care in North Dakota — or any long-term care setting — requires evaluating multiple funding sources. With nursing home costs at $11,528/month (20% above the national average), a 60-month look-back period, and a $3,000 asset limit, advance planning is essential. North Dakota long-term care insurance policies, personal savings, veterans benefits, and Medicaid each play a role. Key steps include:

• Understanding your current financial position relative to North Dakota's Medicaid eligibility thresholds
• Knowing that North Dakota has no set income limit for Nursing Home Medicaid — nearly all income goes toward care costs
• Taking advantage of MSP-PC to hire friends and select relatives as Qualified Service Providers for paid caregiving
• Leveraging North Dakota's MMNA ($2,644) to protect the non-applicant spouse's income
• Recognizing that North Dakota does not count VA Aid & Attendance or Housebound benefits as income
• Understanding that North Dakota does not use Miller Trusts — the Medically Needy / Spend-Down program ($1,174 MNIL single, $1,587 couple) is the pathway for applicants over the HCBS/Regular Medicaid income limit
• Knowing that IRAs/401Ks in payout status (RMD being withdrawn) are exempt assets in North Dakota
• Knowing the $3,000 individual asset limit is higher than the $2,000 standard in most states
• Consulting with a North Dakota elder law attorney or Certified Medicaid Planner to protect assets and avoid look-back penalties

Estate Recovery: Protecting Your Home in North Dakota

North Dakota operates a Medicaid Estate Recovery Program (MERP), which allows the state to seek reimbursement from a deceased Medicaid beneficiary's estate for long-term care costs paid by Medicaid. This can include the family home if proper protections are not in place. The primary home is automatically exempt if the applicant's spouse, child under 21, or permanently blind or disabled child (of any age) lives in it.

If no qualifying family member lives in the home, there is a home equity interest limit of $730,000 (in 2026). If neither the applicant nor qualifying family live in the home, the applicant must demonstrate Intent to Return. There is no home equity interest limit for Regular Medicaid. The home is NOT exempt from estate recovery — families should consult a North Dakota elder law attorney to explore legal protections.

Regional Cost Variations Across North Dakota

Long-term care costs in North Dakota vary by region. Fargo (Cass County — ND's largest metro) typically sees the highest costs due to higher demand. Bismarck (the state capital) and Grand Forks represent mid-range markets. Minot and the oil-producing western region (Williston, Dickinson) have seen cost fluctuations tied to the energy economy. Rural areas across central and southeastern North Dakota, including Native American reservations, generally have fewer providers and more limited home care availability.

Application Timeline and Process

North Dakota Medicaid applications can be submitted through several channels:

• Apply online at the North Dakota Medicaid portal
• Fill out a Health Care Application for the Elderly and Disabled and submit to a County Human Service Zone office
• Contact a local Human Service Zone office to request a mailed application
• Call the Department of Human Services at 1-866-614-6005 for questions or assistance

Applicants should be certain they meet all eligibility requirements prior to applying. For persons over the income and/or asset limits, or unsure of eligibility, Medicaid Planning is strongly recommended. Processing times vary but typically take 45–90 days.

Federal Policy Update: One Big Beautiful Bill Act (OBBBA)

The One Big Beautiful Bill Act (OBBBA) includes approximately $1 trillion in Medicaid cuts over 10 years. While Nursing Home Medicaid is largely protected from future funding reductions, Home and Community Based Services (HCBS) — including North Dakota's Aged and Disabled Waiver, MSP-PC, and PACE — are likely targets for cuts. This law is still facing legal challenges. Families relying on or planning to use HCBS should monitor developments and consider applying early.

Last updated: September 2026. Data sources: North Dakota Department of Human Services, CareScout 2025 care cost survey (updated March 2026). All Medicaid figures reflect 2026 eligibility thresholds. This guide is for informational purposes only and does not constitute legal or financial advice.