New Hampshire and the ACA’s Medicaid expansion

CMS rejected work requirement proposal in 2016, but approved it in 2018. Work requirement will take effect in 2019. State is seeking federal approval to switch from PAP to Medicaid managed care

new-hampshire Medicaid guide

Medicaid expansion in New Hampshire

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.

New Hampshire is one of the states that expanded Medicaid in their own way, obtaining a waiver from CMS that allows 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 allows 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.

PAP utilizes Medicaid funds to pay QHP premiums for Medicaid-eligible enrollees (other than the medically-frail and Medicaid-eligible enrollees who are enrolled in an employer-sponsored plan and receive help from New Hampshire Medicaid in paying the premiums). PAP also covers the QHP cost-sharing that exceeds Medicaid levels. So PAP enrollees don’t pay any more than they would if New Hampshire had continued to use traditional Medicaid coverage, but they’re enrolled in the same QHPs as other residents with higher incomes who either receive premium subsidies or pay 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) that, if approved, would abandon the current PAP system and switch to a Medicaid managed care system instead, as well as eliminate the 90-day retroactive eligibility for Medicaid. The legislation also calls 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 waiver renewal that was approved by CMS (details below), New Hampshire Health Protection Program enrollees aged 19 to 64 will 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, starting as early as January 2019.

As of October 2016, there were 41,714 people enrolled in QHPs through PAP in the New Hampshire exchange. By July 2018, PAP enrollment in QHPs stood at 40,447 — slightly lower but essentially unchanged since late 2016. Total enrollment in the New Hampshire Health Protection Program (ie, Medicaid expansion) stood at 52,642 as of early 2018, including the medically frail and those receiving assistance with the cost of employer-sponsored insurance.

Legislation to extend Medicaid expansion through 2018

Although lawmakers agreed to expand Medicaid, 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 would continue 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.

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

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

  • A work requirement. Able-bodied, childless adults must 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 uses 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.

CMS approves Medicaid work requirement in 2018, will take effect in 2019

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.

The work requirement will apply to Medicaid expansion enrollees aged 19-64, unless they’re otherwise exempt. The work requirement will be implemened as early as January 2019, and enrollees will have 75 days after the work requirement is implemented to begin complying.

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 will 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.

The Trump Administration has already approved work requirements in three other states in 2018: KentuckyArkansas, and Indiana. New Hampshire joins them as the fourth state to receive federal approval to implement a work requirement. And New Hampshire’s work requirement is the most strict to be approved thus far, as the other approved work requirements are for 80 hours per month (in the case of Indiana, it’s 20 hours per week, but it will start at just 5 hours per week and gradually ramp up to 20 hours per week).

Several other states have pending proposals for work requirements, and others are considering submitting work requirement proposals for federal approval.

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 calls 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 (only New Hampshire and Arkansas purchase private plans in the exchange for Medicaid expansion enrollees). The new program would be called the New Hampshire Granite Advantage Health Care Program, and would replace the New Hampshire Health Protection Program.

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
  • 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 has already approved. It would exempt pregnant women, parents or caretakers of dependent children under 13 years of age, parents or caretakers who live with a child of any age with developmental disabilities, drug court participants, disabled or medically frail enrollees, and people who are already in compliance with SNAP/TANF work requirements.

The legislation calls for non-exempt enrollees to work at least 600 hours every six months, which is similar to the 100 hours per week requirement in the waiver that CMS has already approved. By measuring total work over a six month period, enrollees are 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 based on an average of 25 hours per week, but it’s more flexible than the initial Senate bill, which would have required 100 hours per month. It’s not clear whether the state will submit an amendment to CMS, altering the terms of the already-approved work requirement, if S.B.313 is enacted.

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 is 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 would contract with private insurers to offer Medicaid managed care, and enrollees would select from among the available Medicaid managed care organizations (MCO). There would be a 90-day transition period from PAP to Medicaid managed care, and the managed care insurers would have to ensure continuity of care during the transition.

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 is covering 6 percent of the cost of Medicaid expansion in 2018, the federal government has notified the state that there are compliance concerns with the fact that a portion of the state’s funding is 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) is 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 notes 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 supports GOP lawmakers’ efforts to impose a work requirement.

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 10,081 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 2017, total enrollment in Medicaid/CHIP in New Hampshire increased by 62,739 people – a 49 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 5.9 percent by 2016 — nearly 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.

How New Hampshire’s Medicaid expansion differs

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 are eligible for the New Hampshire Health Protection Program and also have access to employer-sponsored health insurance are required to enroll in the employer-sponsored plan if it is 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 have not transitioned to PAP. Neither have medically-frail Medicaid enrollees, including people in nursing homes.

If S.B.313 is enacted and the federal government provides approval, New Hampshire will abandon the PAP system and transition to a regular Medicaid managed care system instead.


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.

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