New Hampshire and the ACA’s Medicaid expansion

CMS rejected work requirement proposal in 2016, but approved it in 2018, effective in 2019. Medicaid expansion has switched from exchange plans to Medicaid managed care

new-hampshire Medicaid guide

Medicaid expansion in New Hampshire

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Although low-income residents in New Hampshire did not have access to expanded Medicaid in the first half of 2014, the state did expand coverage mid-year, and applications for the newly-expanded Medicaid program were available as of July 1, 2014, for coverage effective August 15. In the first three months, 18,000 people – out of a projected 50,000 who were eligible – enrolled. Many of these residents had no health insurance prior to the expansion of Medicaid. Some states significantly underestimated how many people would become eligible for Medicaid under expansion, but that’s not the case in New Hampshire, where enrollment is only a little over 50,000 people.

New Hampshire is one of the states that expanded Medicaid in their own way, obtaining a waiver from CMS that allowed the New Hampshire Health Protection Program to be slightly different from straight Medicaid expansion as called for in the ACA. The waiver that was approved by the Obama Administration allowed for a privatized solution to Medicaid expansion, and most members were transitioning to subsidized private coverage (QHPs in the exchange) as of 2016, under a system called the Premium Assistance Program, or PAP (in 2014 and 2015, prior to the transition to PAP, Medicaid expansion in New Hampshire had functioned in much the same way it did in other states). As of November 2018, enrollment in New Hampshire PAP stood at 39,354 people.

PAP utilized Medicaid funds to pay QHP premiums for Medicaid-eligible enrollees (other than the medically-frail and Medicaid-eligible enrollees who were enrolled in an employer-sponsored plan and received help from New Hampshire Medicaid in paying the premiums). PAP also covered the QHP cost-sharing that exceeded Medicaid levels. So PAP enrollees didn’t pay any more than they would have if New Hampshire had continued to use traditional Medicaid coverage, but they were enrolled in the same QHPs as other residents with higher incomes who either received premium subsidies or paid full price for their coverage.

However, New Hampshire enacted legislation in 2018 that called for the state to submit a new waiver proposal to CMS (submitted in July 2018, along with a proposal to extend the state’s Medicaid expansion waiver for five more years), requesting permission to abandon the PAP system and switch to a Medicaid managed care system instead, as well as eliminate the 90-day retroactive eligibility for Medicaid.

The proposal was approved by CMS in late November 2018, but the state had already communicated to enrollees, in September 2018, that their coverage would switch to Medicaid managed care as of January 2019. And the rate filings that QHP insurers submitted in the summer of 2018 included the assumption that PAP would no longer be operational after the end of 2018. So the state’s PAP experiment only lasted three years (2016-2018), with New Hampshire transitioning to a regular Medicaid managed care model as of 2019.

New Hampshire’s 2018 legislation also called for the state to seek federal approval for a Medicaid work requirement, but that was part of a waiver renewal proposal that New Hampshire had already submitted to CMS, and which was approved in May 2018. Under the terms of the approved waiver renewal (details below), New Hampshire Granite Advantage Program (formerly the Health Protection Program) enrollees aged 19 to 64 have to participate in “community engagement” (work, school, job training, community service, etc.) at least 100 hours per month in order to maintain eligibility for Medicaid.

The Granite Advantage program‘s work requirement took effect in January 2019, but it was being challenged in court by March 2019, and Democratic lawmakers have introduced legislation to modify the work requirement and end it altogether if the state determines that more than 500 people will lose their coverage as a result of non-compliance with the work requirement (for perspective, more than 18,000 people have lost coverage in Arkansas under the terms of a work requirement that took effect in mid-2018, but more than 250,000 people had gained Medicaid coverage in Arkansas as a result of Medicaid expansion, whereas fewer than 50,000 did so in New Hampshire).

Medicaid expansion was initially approved for 2 years, then for 2 more years. Latest extension is for 5 additional years

Although lawmakers agreed to expand Medicaid under the ACA, they included a sunset provision that would terminate Medicaid expansion in the state as of the end of 2016 unless the legislature specifically approved funding beyond that point.

Then-Governor Maggie Hassan included proposed funding for continued Medicaid expansion in her fiscal year 2016-2017 budget, but in March 2015, New Hampshire lawmakers voted to remove extended Medicaid expansion funding from the budget.

Going into the 2016 legislative session, there was no provision to fund Medicaid expansion past the end of 2016. In March 2016, lawmakers in the New Hampshire House of Representatives passed HB1696, which extended Medicaid expansion through the end of 2018, but with more restrictions on the program (the original version of the bill called for an extension through 2020, but the version that was passed only provided a two-year funding extension).

The bill passed easily, but there was a 181-181 tie vote over an amendment to remove the language in the bill that would have ended Medicaid expansion in New Hampshire if CMS had not approved the new restrictions the state was proposing for PAP. House Speaker Shawn Jasper, a Republican who was originally opposed to Medicaid expansion but began to support it in 2015, cast the tie-breaking vote in favor of removing the all-or-nothing language in the bill. That meant Medicaid expansion would continue to be funded (at least through 2018), regardless of whether the state’s new waiver was approved or rejected by CMS.

On March 31, 2016, the Senate also passed the bill, with a 16 – 8 vote, and Governor Hassan signed it on April 5.

In 2018, New Hampshire enacted SB313, which extends Medicaid expansion for another five years, through 2023. That legislation was also the impetus for the transition to Medicaid managed care and reiterated the need to implement a Medicaid work requirement, although that was already pending CMS approval when SB313 was being considered by lawmakers, and CMS approval for the work requirement came before SB313 was sent to the governor.

Obama Administration CMS rejected work requirement in 2016, but Medicaid expansion continued

After HB1696 was enacted in 2016, the state then had to request a waiver modification from CMS in order to implement the new requirements called for in the legislation, which were generally more strict than the Obama Administration had allowed in any other states. They included:

  • A work requirement. HB1696 called for able-bodied, childless adults to participate in at least 30 hours per week of work, job training, education towards obtaining a job, or other related activities. But work requirements were a non-starter for CMS under the Obama Administration. An amendment was eventually added to HB1696 — after much debate — that allowed expansion to continue even if CMS wouldn’t approve the work requirement.
  • A premium requirement of $25/month (up to two percent of household income) for able-bodied adults with income between 101 percent and 138 percent of the poverty level, and $10/month for those with income up to 100 percent of the poverty level. There would be a 60 day grace period for non-payment of premiums, after which coverage would be terminated and the person wouldn’t be eligible to re-enroll for six months.
  • Copays for non-emergency use of an emergency room.

New Hampshire’s Medicaid expansion already utilized a CMS waiver, as the state was at that point using Medicaid funds to purchase private coverage in the exchange for Medicaid-eligible residents. The changes called for in HB1696 required an additional waiver, which was submitted to CMS in August 2016.

On November 1, 2016, CMS replied to New Hampshire’s waiver amendment proposal, rejecting most of it, including the work requirement. CMS agreed to allow copays for non-emergency use of emergency rooms, but “only if the request satisfies the requirements of sections 1916(f) and 1115 of the Social Security Act, including the requirement that the waiver promote the objectives of the Medicaid program.

Medicaid work requirement took effect March 1, 2019; enrollees must begin reporting community engagement hours by June 1 — but legal roadblocks might still derail the program

Because of Speaker Jasper’s vote to continue the program regardless of whether the waiver modifications were supported by CMS, Medicaid expansion continued in New Hampshire in 2017 and 2018, despite the Obama Administration’s refusal to allow the state to impose a work requirement.

But with the Trump Administration assuming office in early 2017, GOP lawmakers in New Hampshire passed a budget measure requiring the state to seek a work requirement for Medicaid by April 2018, or else Medicaid expansion would expire at the end of 2018. The state submitted a work requirement waiver amendment to CMS in October 2017, which was approved by CMS in May 2018.

Later in 2018, CMS revised the work requirement approval, making them tougher on enrollees. Under the new rules, extra hours cannot be carried forward to meet a future month’s work requirement. However, an enrollee whose prior month hours were deficient can make those hours up during the current month. CMS clarifies, however, that an enrollee cannot be perpetually behind and making up hours during each month of a year.

The work requirement applies to Medicaid expansion enrollees aged 19-64, unless they’re otherwise exempt. The work requirement was implemented in March 2019, and enrollees must begin reporting their community engagement hours to the state by June 1, 2019. In February, the state began sending letters to enrollees to notify them of the mandatory work requirements, and there is a page on the NH DHHS website that includes information on how the reporting works. But despite the fact that the state has rolled out the work requirement and appears to be moving forward with implementation, questions remain as to whether the program will actually be allowed to proceed, after a federal judge struck down similar work requirements in other states.

Assuming the work requirement is implemented, non-exempt enrollees will have to work (or participate in school, job training, community service, substance abuse treatment, job skills development, etc.) for at least 100 hours per month in order to remain eligible for Medicaid. Exempt populations include pregnant women (including up to 60 days post-partum), disabled or medically frail individuals, parents/caretakers of a child under age 6 (only one parent per household can claim this exemption), parents/caretakers caring for a disabled dependent, or people who experience a hospitalization or serious illness.

For perspective, the other states that have sought approval for Medicaid work requirements are generally setting the minimum requirement at 80 hours per month or 20 hours per week. They also generally have longer time frames before a person loses coverage — in New Hampshire, it’s slated to be essentially the second month after a person fails to comply with the work requirement, unless they are able to get into compliance in the intervening month.

As of 2019, eight states have received federal approval for Medicaid work requirements and several others have pending proposals. But a federal judge has twice blocked Kentucky’s Medicaid work requirement from taking effect, and the work requirement in Arkansas (which took effect in mid-2018) was struck down in March 2019. This has has added legal uncertainty to the Medicaid work requirement concept in other states, including New Hampshire.

Extending Medicaid expansion through 2023, with a switch from PAP to managed care

In 2018, Republican Senators in New Hampshire introduced S.B.313, which called for a work requirement (although CMS has already approved a work requirement as part of the waiver approval that was granted in May 2018), along with a new Medicaid expansion program that will use Medicaid managed care — as most of the country does — instead of the Premium Assistance Program (as of 2018, only New Hampshire and Arkansas purchased private plans in the exchange for Medicaid expansion enrollees). The new program, dubbed the New Hampshire Granite Advantage Health Care Program, replaced the New Hampshire Health Protection Program as of January 2019.

The Senate passed S.B.313 in March 2018, with an 18-7 vote. In the House, an amendment was approved, and the House voted 222-125 that the bill ought to pass. The bill ultimately did pass, and was signed into law in July 2018. Within two weeks, the state submitted a proposal to CMS, seeking approval to implement the changes called for in S.B.313. Those include:

  • Switching from PAP to Medicaid managed care (as of September 2018, the state had already communicated the switch to managed care on their website, although the waiver proposal didn’t receive receive CMS approval until late November; the change was implemented in January 2019)
  • Implementing a work requirement (the waiver proposal for this has already been approved)
  • Changing the way the state’s share of Medicaid expansion funding is generated
  • Eliminating retroactive coverage for Medicaid

Work requirement — and a subsidy for employers who hire Medicaid enrollees

The work requirement in S.B.313 aligns with the work requirement that CMS had already approved. The legislation called for non-exempt enrollees to work at least 600 hours every six months, which was similar to the 100 hours per week requirement in the waiver that CMS had already approved. By measuring total work over a six month period, enrollees would have been protected from losing Medicaid due to temporary drops in employment, as long as they can make up the lost hours within the six-month window. The legislation calling for 600 hours of work every six months is more flexible than the initial Senate bill (and the state’s approved waiver proposal) which requires 100 hours per month. However, the terms of the already-approved work requirement were not adjusted to reflect the 600 hours every six months requirement.

In addition, S.B.313 also calls for the state to use up to $3 million in TANF (Temporary Assistance for Needy Families) funding, through June 30, 2019, to provide subsidies to employers who hire people who are eligible for Medicaid expansion in New Hampshire. The employer would get $2,000 at the time of the hire, and another $2,000 after the enrollee has been working for three months.

The legislation also has an asset test (with a $25,000 maximum asset limit, after accounting for excludable assets, such as a primary residence, household furnishings, and one vehicle), which would only be implemented if future changes in federal law allow it. As a result of the ACA, Medicaid currently only allows asset tests for long-term care coverage (eg, seniors who use Medicaid to pay for nursing home care) and for people obtaining coverage based on eligibility guidelines that go beyond income, but that could change if federal rules change.

Transition to managed care

Another provision of S.B.313 was to transition Medicaid expansion in New Hampshire away from the Premium Assistance Program (PAP) and utilize Medicaid managed care instead, as most states do.

The state has contracted with two Medicaid managed care health plans: New Hampshire Healthy Families and Well Sense Health Plan. PAP enrollees were able to select whichever plan they prefer, and were transitioned to the new plans as of January 2019.

State funding changes for Medicaid expansion cost

The federal government paid 100 percent of the cost of Medicaid expansion from 2014 through 2016. In 2017, states had to begin paying 5 percent of the cost, and that is gradually increasing until it will reach 10 percent in 2020, and remain at that level going forward. HB1696 required health insurance companies and hospitals in the state to pay fees toward the state’s portion of the cost of Medicaid expansion. But the federal government will always pay at least 90 percent of the cost of covering the Medicaid expansion population. If New Hampshire hadn’t reauthorized Medicaid expansion past the end of 2016, the state would have missed out on hundreds of millions of dollars in federal funding.

Although New Hampshire was covering 6 percent of the cost of Medicaid expansion in 2018, the federal government had notified the state that there were compliance concerns with the fact that a portion of the state’s funding was coming from donations from providers, and indicated that the state would have to make legislative changes to the funding model for the state’s portion of the cost of Medicaid expansion by the 2019 fiscal year.

So the third provision of S.B.313 (in addition to the switch to managed care and the work requirement) was to increase the percentage of revenue from liquor sales that gets deposited into the state’s Alcohol Abuse Prevention and Treatment Fund (AAPTF) from 3.4 percent to 5 percent, and then transfer that funding from AAPTF to the new Medicaid expansion program (the New Hampshire Granite Advantage Health Care Program).

The legislation noted that the transfer of funds from AAPTF to Medicaid expansion would be to ensure the “delivery of substance use disorder prevention, treatment, and recovery and other behavioral health services for persons enrolled in the New Hampshire granite advantage health care program,” but the transfer is also dependent on the state being able to secure federal funding to cover the expenses that would otherwise have been funded via AAPTF. So federal approval would be needed for this portion of S.B.313 as well, since the federal government would have to agree to provide funding for the current alcohol abuse prevention and treatment activities currently funded by AAPTF.

Gubernatorial leadership on Medicaid

Former Governor Maggie Hassan was instrumental in expanding Medicaid in New Hampshire, and worked to ensure continued funding. But Hassan did not seek re-election to the governor’s office — she ran instead for the U.S. Senate in 2016, challenging incumbent Kelly Ayotte, who opposed the ACA and Medicaid expansion. The Hassan-Ayotte race was tight, but Hassan won, assuming office in the Senate in January 2017.

Republican Chris Sununu won the gubernatorial election in New Hampshire in 2016. Sununu had previously been uncommitted in terms of his views on Medicaid expansion, but after his win, Sununu said that he did not plan to eliminate Medicaid expansion in New Hampshire, but wanted to ensure that the program is a temporary solution while people work to obtain their own health insurance (either in the individual market or from an employer), rather than a permanent solution. And in early 2017, Sununu said that New Hampshire had seen “great results” from expanding Medicaid. Governor Sununu has since remained committed to keeping Medicaid expansion intact, but has supported GOP lawmakers’ efforts to impose the work requirement that takes effect in 2019.

Expanded coverage effective August 15, 2014

For the first half of 2014, New Hampshire residents were only able to enroll in Medicaid if they were eligible based on the pre-expansion guidelines. But as of July 2014, the new guidelines became effective, and eligible residents were able to start enrolling in expanded Medicaid with coverage effective August 15.

Medicaid in New Hampshire is now available for all adults with household incomes up to 138 percent of poverty. Children are eligible for CHIP (Children’s Health Insurance Program) with household incomes up to 323 percent of poverty (the CHIP guidelines are the same as they were pre-expansion). Pregnant women are eligible for Medicaid with household incomes up to 196 percent of poverty.

How do I apply for Medicaid in NH?

  • You can download a paper application. (The state website also has versions available in Spanish and Nepali.) Complete it, and either fax it to (603) 271-8604 or mail it to the district office that serves your area.
  • You can also call 1-800-852-3345, extension 9700 and apply for Medicaid by phone.

NH Medicaid enrollment numbers

From October 1, 2013 until mid-April 2014, 7,235 exchange applicants in New Hampshire enrolled in the state’s pre-expansion Medicaid program. And from the fall of 2013 to June 2014, total Medicaid enrollment in New Hampshire increased by more than 10,000 people. These individuals were already eligible for Medicaid based on the previous guidelines, but didn’t enroll until 2014.

Based on the expanded eligibility criteria, New Hampshire officials estimated that about 50,000 people would be newly eligible for Medicaid coverage. From the fall of 2013 to December 2018, total enrollment in Medicaid/CHIP in New Hampshire increased by 53,242 people —a 42 percent increase.  Not all of the new enrollees were newly eligible, but there’s no doubt that Medicaid expansion has significantly increased the Medicaid-covered population in the state.

And that, in turn, has had a significant impact on the uninsured rate.  In 2013, 10.7 percent of the population was uninsured, according to U.S. Census data. That had fallen to 5.8 percent by 2017 — more than a 45 percent decrease.

Medicaid expansion in New Hampshire was quite contentious, but former Governor Maggie Hassan eventually succeeded in her efforts to expand Medicaid — using a privatized approach — to people with incomes up to 138 percent of poverty (133 percent, but with a 5 percent income disregard for people whose incomes are slightly over 133 percent of FPL).

On March 27, 2014, Gov Hassan signed Senate Bill 413 into law, setting New Hampshire on track to become the 27th state (including DC) to expand Medicaid.

The switch to privatized Medicaid expansion went into effect in 2016, but was short-lived. As of 2019, New Hampshire transitioned Medicaid expansion enrollees to Medicaid managed care plans instead.

How New Hampshire’s Medicaid expansion differed from other states’ approaches from 2016-2018

Until 2016, the program worked much the same as Medicaid expansion in the states that have followed the expansion guidelines in the ACA. The state used federal Medicaid funds to provide New Hampshire Health Protection Program coverage for legally-present residents with incomes below 138 percent of poverty.

During this time however, the state’s Bridge Program gave eligible beneficiaries the option of enrolling in a private plan through the exchange and having the cost subsidized with Medicaid funding.

But starting in 2016, New Hampshire moved most Medicaid expansion enrollees to private coverage obtained through the exchange, utilizing Medicaid funding to subsidize the cost of the plans. This approach, called the Premium Assistance Program, or PAP, was a bipartisan compromise between those who wanted to simply expand the existing Medicaid program and those who preferred an approach that would provide private coverage for the state’s low-income residents.

New Hampshire’s Medicaid waiver to switch to a privatized system was approved by CMS in March 2015.

Residents who were eligible for the New Hampshire Health Protection Program and also had access to employer-sponsored health insurance were required to enroll in the employer-sponsored plan if it was deemed cost-effective. But under the state’s Health Insurance Premium Payment (HIPP) program, the member can receive assistance in paying premiums and cost-sharing for the employer-sponsored plan, using Medicaid funds. The state makes the determination of whether it’s more cost effective to cover the member under Medicaid, or to opt for the employer-sponsored plan with financial assistance through the HIPP program. But as of 2017, this program only had 81 enrollees.

Enrollees in the HIPP program were not transitioned to PAP. Neither were medically-frail Medicaid enrollees, including people in nursing homes.

But under the terms of S.B.313 and the federal waiver approval granted by CMS in November 2018, New Hampshire has abandoned the PAP system and transitioned to a regular Medicaid managed care system as of 2019.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

How to apply in NH

You can apply through HealthCare.gov or directly through the New Hampshire Department of Health and Human Services. You can also use a paper application or you can call 1-800-852-3345, extension 9700 and apply by phone.

Eligibility: Adults with household incomes up to 133% of poverty, and pregnant women with incomes up to 196% of poverty. Children are eligible for CHIP with household incomes up to 323% of poverty.

New Hampshire section