North Dakota law mandates that every child support order include a medical support provision requiring one or both parents to provide health insurance coverage for minor children. Under N.D.C.C. § 14-09-08.10 and NDAC § 75-02-04.1, courts must establish medical support obligations whenever they establish child support, ensuring children have access to healthcare coverage regardless of parental marital status. The parent receiving support must provide insurance if available at low or no cost; otherwise, the paying parent must provide coverage if available at reasonable cost through an employer, union, or group plan.
Key Facts: Health Insurance and Child Support in North Dakota
| Factor | North Dakota Requirement |
|---|---|
| Filing Fee | $160 (effective July 1, 2025) |
| Waiting Period | None |
| Residency Requirement | 6 months |
| Grounds | Irreconcilable differences (no-fault) |
| Property Division | Equitable distribution |
| Medical Support Required | Yes, in all child support orders |
| Insurance Cost Standard | Reasonable cost (employer/group basis) |
| Premium Sharing | Proportional to parental income |
| Withholding Limit | 50% of disposable income |
How North Dakota Defines Medical Support Obligations
North Dakota requires that health insurance child support North Dakota orders include specific provisions for medical coverage as part of every child support determination. Under NDAC § 75-02-04.1-08.2, medical support obligations are established simultaneously with the basic child support obligation, creating a comprehensive framework that addresses both monthly cash payments and healthcare coverage. The medical support order must specify which parent provides insurance, how premiums are shared, and how unreimbursed medical expenses are divided between parents.
North Dakota courts apply a two-tier priority system for determining which parent must provide health insurance coverage. The custodial parent (the parent receiving child support) must provide coverage if health insurance is available at low cost or no cost, such as through Medicaid, the Children's Health Insurance Program (CHIP), or a no-premium employer plan. If the custodial parent cannot obtain low-cost coverage, the obligation shifts to the noncustodial parent (the parent paying support), who must provide insurance if available at reasonable cost.
The state defines reasonable cost as insurance available through an employer, union, or group basis, regardless of service delivery mechanism. This definition focuses on the availability structure rather than a specific percentage of income, distinguishing North Dakota from states that cap reasonable cost at 5% of gross income. Courts consider the scope of covered services and the cost of coverage when determining whether employer-provided insurance meets the reasonable cost standard.
Which Parent Must Provide Health Insurance Coverage
North Dakota law establishes a clear hierarchy for health insurance child support North Dakota obligations based on availability and cost. The parent receiving support carries the primary obligation when insurance is available at low cost or no cost through their employment, public programs, or other group coverage. If the receiving parent cannot access low-cost coverage, the paying parent must provide insurance through their employer, union, or group plan if available at reasonable cost.
The medical support order must identify the specific parent responsible for maintaining coverage and the consequences for failing to maintain required insurance. When neither parent can provide coverage at reasonable cost, courts may order parents to share the cost of marketplace coverage or other private insurance proportionally based on their respective incomes. North Dakota courts recognize that health insurance availability changes with employment situations, requiring modification procedures when coverage circumstances shift.
Employer-based insurance remains the most common source of coverage in North Dakota child support cases. When a parent provides insurance through work, only the incremental cost attributable to adding the child to the policy counts toward the medical support obligation, not the entire family premium. This distinction prevents double-counting when the parent already maintains coverage for themselves or other dependents.
How Health Insurance Premiums Are Shared Between Parents
North Dakota calculates the allocation of health insurance premiums based on each parent's proportional share of combined parental income under NDAC § 75-02-04.1-01(6)(d). If Parent A earns $4,000 monthly net income and Parent B earns $6,000 monthly net income, their combined income totals $10,000, making Parent A responsible for 40% and Parent B responsible for 60% of any shared expenses. When Parent A pays a $300 monthly premium for the child's coverage, Parent B owes 60% of that cost ($180) as part of the child support calculation.
The premium-sharing calculation applies only to the actual cost of covering the child, excluding portions attributable to the parent's own coverage or other dependents. Courts require documentation of the child-only cost when employer plans bundle family coverage. If precise figures are unavailable, courts may estimate the child's portion by dividing the family premium by the number of covered individuals or using employer-provided cost breakdowns.
Health insurance premiums paid by the obligor can be deducted from gross income when calculating net income for child support purposes. The North Dakota Supreme Court confirmed in Boldt v. Boldt (2021 ND 213, 966 N.W.2d 897) that when the obligee provides health insurance coverage for children through employment-based insurance and the obligor is required to pay a portion of the premiums, the obligor is entitled to deduct that reimbursement amount from gross income.
Understanding the National Medical Support Notice Process
The National Medical Support Notice (NMSN) is a two-part federal form that North Dakota uses to enforce health insurance obligations through employers. When a child support order requires a parent to provide health coverage, the North Dakota Child Support Division sends the NMSN directly to the parent's employer, triggering automatic enrollment procedures. Employers must respond within 20 business days of receiving the notice by either enrolling the child in available coverage or documenting why coverage cannot be provided.
Part A of the NMSN (Notice to Withhold for Health Care Coverage) directs the employer to withhold premium payments from the employee's wages. If the employee has no available health insurance, the employer completes Part A and returns it to the issuing Child Support office. Part B (Medical Support Notice to Plan Administrator) goes to the health plan administrator, who must enroll the child and provide the custodial parent with plan documents and insurance cards.
North Dakota law limits total withholding for child support and health insurance premiums to 50% of the employee's disposable income when the principal place of employment is in North Dakota. The employer must prioritize the cash child support withholding over health insurance premium withholding when both cannot be satisfied within the 50% limit. This prioritization ensures children receive direct support payments before premium allocations.
Calculating Child Support With Medical Support Additions
North Dakota calculates child support using a percentage-of-income model under NDAC § 75-02-04.1, then adds health insurance premiums and childcare costs to the base obligation. The state calculator applies the guidelines schedule to the obligor's net income after deducting federal and state taxes, FICA (7.65%), mandatory retirement contributions, and the self-support allowance of approximately $1,255 per month for 2026. The resulting base amount represents the minimum monthly obligation before medical support additions.
Health insurance premiums for children and childcare costs are added to the support obligation and shared proportionally between parents based on their respective incomes. These mandatory add-on expenses can substantially increase the total child support obligation beyond the guidelines amount. A parent paying $200 monthly for the child's health insurance premium would see their total obligation rise by the other parent's proportional share of that cost.
North Dakota child support for one child ranges from approximately $140 per month at $1,000 monthly net income to a maximum of $3,500 per month at the $25,000 net income cap under NDAC § 75-02-04.1-10. The guidelines use a graduated approach where the effective percentage decreases as income rises, reflecting research showing that higher-income families spend a smaller proportion of earnings on basic child-rearing costs.
How Parenting Time Affects Medical Support Obligations
North Dakota child custody arrangements directly impact health insurance child support North Dakota calculations through the joint custody adjustment formula. Parents with more than 100 overnights annually qualify for the joint child custody formula under the guidelines, which reduces the base child support obligation. However, medical support obligations typically remain proportional to income regardless of custody arrangement, ensuring consistent healthcare coverage regardless of where the child primarily resides.
Sole physical custody means the nonresidential parent is scheduled for 100 days or fewer with the children per year under North Dakota guidelines. In these arrangements, the noncustodial parent typically pays full child support according to the guidelines schedule plus their proportional share of health insurance premiums. The custodial parent maintains day-to-day responsibility for healthcare decisions and insurance card management while the support order specifies premium-sharing obligations.
Joint physical custody arrangements with more than 100 overnights per year trigger different calculation formulas that account for shared parenting time. Both parents may carry the child on their respective health insurance policies in some joint custody situations, potentially creating dual coverage that requires coordination of benefits. Courts typically designate one parent's insurance as primary coverage and the other's as secondary to prevent billing complications.
Division of Unreimbursed Medical Expenses
North Dakota child support orders must address unreimbursed medical expenses, including copayments, deductibles, prescription costs, and services not covered by insurance. The standard approach divides these costs proportionally between parents based on their respective incomes, using the same ratio applied to health insurance premiums. Courts typically include specific language requiring parents to share documentation of medical expenses and establish reimbursement timelines.
Unreimbursed medical expenses covered by North Dakota support orders typically include doctor visit copays, hospital deductibles, prescription medication costs, dental procedures, orthodontia, vision care including eyeglasses and contacts, mental health services, and medical equipment. Courts distinguish between routine expenses that parents absorb as part of everyday parenting and extraordinary medical costs that require formal reimbursement between parents.
Most North Dakota orders require the parent incurring the expense to provide documentation (receipts, insurance explanation of benefits) within 30 days and specify that the other parent must reimburse their share within 30 days of receiving documentation. Failure to provide timely documentation may forfeit the right to reimbursement, while failure to reimburse may be enforced as a child support arrearage with applicable interest at 10% annually under N.D.C.C. § 14-09-09.10.
Modification of Medical Support Orders
North Dakota permits modification of medical support orders when material changes occur in either parent's circumstances, including changes in employment-based insurance availability, premium costs, or the child's healthcare needs. The filing fee for a child support modification motion is $160 as of July 1, 2025, the same fee that applies to original divorce filings. Parents must demonstrate a significant change in circumstances since the original order to justify modification.
Common grounds for modifying medical support orders include loss of employer-provided insurance, significant premium increases, changes in the child's medical needs, or one parent gaining access to lower-cost coverage. The North Dakota Child Support Division offers administrative review and adjustment services that may avoid the need for formal court proceedings in some modification cases. Reviews examine whether current support amounts, including medical support, reflect current circumstances.
Health insurance availability often changes when parents change jobs, making modification a recurring need throughout the child support obligation period. Courts encourage parents to notify each other promptly when coverage changes occur and to cooperate in transitioning children to new insurance plans. The NMSN process automatically updates when the obligor changes employers, but voluntary communication between parents prevents coverage gaps.
Enforcement of Medical Support Obligations
North Dakota enforces medical support obligations through the same mechanisms used for cash child support, including wage withholding, tax refund interception, professional license suspension, and contempt proceedings. The state eliminated the statute of limitations on child support enforcement effective April 2, 1999, meaning past-due medical support reimbursements can be collected indefinitely regardless of when they accrued. Interest accrues on delinquent medical support at 10% annually.
A payment becomes delinquent under N.D.C.C. § 14-09-09.10 on the first working day after the due date when the unpaid amount equals at least one month's support obligation. This applies to both cash support and medical support reimbursement obligations. The North Dakota Child Support Division can intercept federal and state tax refunds, suspend driver's licenses, and report delinquencies to credit bureaus.
Parents who fail to maintain required health insurance coverage face contempt proceedings and may be held responsible for medical expenses that would have been covered had insurance been in place. Courts may order the non-compliant parent to reimburse 100% of expenses that their insurance would have covered, rather than only their proportional share. This penalty approach incentivizes compliance with insurance maintenance obligations.
Public Health Insurance Programs and Child Support
North Dakota's Children's Health Insurance Program (CHIP) covers uninsured children in families with moderate incomes that exceed Medicaid eligibility thresholds. Families can contact CHIP at (844) 854-4825 to determine eligibility. When children receive Medicaid or CHIP coverage and one parent does not live in the home, families may need to cooperate with Child Support to establish paternity and ensure private health coverage or payment for uncovered medical expenses.
Medicaid enrollment in North Dakota peaked at approximately 136,000 in May 2023 and dropped to about 105,000 by May 2024 following the end of continuous coverage requirements on March 31, 2023. Families with questions about Medicaid eligibility can contact the North Dakota Medicaid Program at (701) 328-2321 or (800) 472-2622. Children covered by Medicaid may still have a medical support order requiring a parent to maintain private insurance when available at reasonable cost.
Child support orders affecting Medicaid recipients must include provisions for reimbursing the state for medical expenses paid on behalf of children. When private insurance becomes available, the order typically requires transition from public coverage to private coverage. This coordination between child support and public benefits ensures children maintain continuous coverage while minimizing taxpayer costs.
Filing for Child Support With Medical Support Provisions
Parents seeking child support orders with medical support provisions file through North Dakota district court using standardized forms available through the North Dakota Courts website (ndcourts.gov). The filing fee is $160 as of July 1, 2025, representing the first fee increase since 1995. Fee waivers are available for parents demonstrating financial hardship at or below 125% of federal poverty guidelines through a Petition for Waiver of Filing Fees and Costs.
North Dakota requires no mandatory waiting period for divorce or child support orders, meaning cases can potentially be finalized within 30 to 90 days for uncontested matters. The plaintiff must be a resident of North Dakota for six consecutive months before the court can grant a final divorce decree under N.D.C.C. § 14-05-17. The residency requirement applies only to the filing spouse; the other parent does not need to reside in North Dakota.
Child support orders may be established through divorce proceedings, paternity actions, or standalone support petitions. All orders must include medical support provisions specifying insurance obligations and unreimbursed expense sharing. The North Dakota Child Support Division at the Department of Health and Human Services provides enforcement and administrative services for established orders, including NMSN processing and wage withholding.
Frequently Asked Questions About Health Insurance and Child Support in North Dakota
Is health insurance required in all North Dakota child support orders?
Yes, North Dakota mandates medical support provisions in every child support order under NDAC § 75-02-04.1. Courts must establish health insurance requirements simultaneously with cash support obligations. The order specifies which parent provides coverage, how premiums are shared proportionally based on income, and how unreimbursed medical expenses are divided. Failure to include medical support provisions renders the order incomplete.
Which parent is required to provide health insurance for the child?
The custodial parent must provide coverage if available at low or no cost through employment, Medicaid, CHIP, or other sources. If low-cost coverage is unavailable to the custodial parent, the noncustodial parent must provide insurance through their employer, union, or group plan if available at reasonable cost. North Dakota defines reasonable cost as insurance available through an employer or group basis, not as a specific percentage of income.
How are health insurance premiums divided between parents in North Dakota?
North Dakota divides health insurance premiums proportionally based on each parent's share of combined parental income under NDAC § 75-02-04.1-01(6)(d). If one parent earns 60% of combined income and the other earns 40%, they share premium costs in the same 60/40 ratio. Only the incremental cost of adding the child to coverage counts, not the entire family premium.
What is the National Medical Support Notice and how does it work?
The NMSN is a federal two-part form sent to employers when a parent is ordered to provide health insurance. Employers must respond within 20 business days by either enrolling the child in available coverage or explaining why coverage cannot be provided. Part A directs wage withholding for premiums, and Part B instructs the plan administrator to enroll the child and send documents to the custodial parent.
Can health insurance withholding exceed child support withholding limits?
No, North Dakota caps total withholding for both child support and health insurance premiums at 50% of disposable income when the principal workplace is in North Dakota. Cash child support withholding takes priority over insurance premium withholding when both cannot be satisfied within the 50% limit. This ensures children receive direct support payments even when full premium withholding is not possible.
How are unreimbursed medical expenses handled in North Dakota?
North Dakota child support orders typically divide unreimbursed medical expenses proportionally between parents based on income shares. Covered expenses include copayments, deductibles, prescriptions, dental, orthodontia, vision care, and mental health services. Most orders require documentation within 30 days and reimbursement within 30 days after documentation. Unpaid reimbursements accrue 10% annual interest.
What happens if a parent fails to maintain required health insurance?
Parents who fail to maintain required coverage face contempt proceedings and may be ordered to pay 100% of medical expenses that would have been covered, rather than only their proportional share. The North Dakota Child Support Division enforces medical support through wage withholding, tax interception, and license suspension. There is no statute of limitations on collecting past-due medical support.
Can medical support orders be modified in North Dakota?
Yes, medical support orders can be modified when material changes occur, including loss of employer insurance, significant premium increases, or changes in the child's medical needs. The modification filing fee is $160 as of July 1, 2025. Parents must demonstrate significant changed circumstances since the original order. The Child Support Division offers administrative review services that may avoid formal court proceedings.
Does parenting time affect medical support obligations?
Parenting time affects the base child support calculation but typically does not change the proportional division of medical support obligations. Parents with more than 100 overnights qualify for joint custody adjustments that reduce cash support. However, health insurance premium sharing remains based on income proportions regardless of custody arrangement. Both parents may carry dual coverage in some joint custody situations.
How does Medicaid affect child support medical support orders?
When children receive Medicaid and one parent lives outside the home, families may need to cooperate with Child Support to ensure private coverage or payment for uncovered expenses. Child support orders affecting Medicaid recipients include provisions for reimbursing the state. When private insurance becomes available at reasonable cost, the order typically requires transition from public to private coverage.
This guide was prepared by Antonio G. Jimenez, Esq. (Florida Bar No. 21022), covering North Dakota divorce and family law. For personalized guidance on health insurance child support North Dakota matters, consult with a licensed North Dakota family law attorney.
Sources: North Dakota Century Code Chapter 14-09, North Dakota Administrative Code Chapter 75-02-04.1, North Dakota Health and Human Services Child Support, North Dakota Court Fee Schedule
Filing fee and court cost information current as of July 2025. Verify current fees with the North Dakota district court clerk before filing.