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New Hampshire and the ACA’s Medicaid expansion

Expansion continues, despite new Republican governor and CMS rejection of work requirement

new-hampshire Medicaid guide

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 utilizing a CMS waiver that allows for a privatized solution to Medicaid expansion, and 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.

As of October 2016, there were 41,714 people enrolled in QHPs through PAP in the New Hampshire exchange.

Legislation to extend Medicaid expansion

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.

Governor 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 than the program currently has (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, the Senate also passed the bill, with a 16 – 8 vote, and Governor Hassan signed it on April 5.

CMS rejects work requirement, but Medicaid expansion continues

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

  • 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. Work requirements have thus far been a non-starter for CMS; the agency has yet to approve a Medicaid expansion waiver with a work requirement. An amendment was eventually added to HB1696 – after much debate – that allows expansion to continue even if CMS won’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 utilizes 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 require an additional waiver, which was submitted to CMS in August 2016.

On November 1, CMS replied to New Hampshire’s waiver amendment proposal, rejecting most of it, including the work requirement (Republicans pushed hard for the work requirement, but CMS has not approved a work requirement in any Medicaid expansion waivers to date). 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.

2017 and beyond

Because of Speaker Jasper’s vote to continue the program regardless of whether the waiver modifications were supported by CMS, Medicaid expansion will continue in 2017 in New Hampshire.

New Hampshire Governor Maggie Hassan, a Democrat, was elected to the U.S. Senate in November 2016, and will move to that role in January 2017 (Hassan defeated Republican incombant, Kelly Ayotte, by a slim margin).

Hassan’s replacement in the Governor’s office is Chris Sununu, a Republican who has expressed opposition to the Affordable Care Act. After his win, Sununu said that he does not plan to eliminate Medicaid expansion in New Hampshire, but wants 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.

Donald Trump’s White House win makes the future of the ACA — including Medicaid expansion — uncertain. But for the time being, nothing has changed, and expanded Medicaid is still available in New Hampshire for 2017. But there is currently no provision to keep funding it past the end of 2018, and the election of Trump and Sununu means there could be significant shifts in the future of Medicaid expansion.

2017 is when states have to begin paying a small portion of the cost of Medicaid expansion (through the end of 2016, it’s fully funded by the federal government). HB1696 asks health insurance companies and hospitals in the state to pay fees that will cover 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.

New Hampshire – a unique expansion of Medicaid

When the ACA was written, one of the fundamental cornerstones of the law was the expansion of Medicaid to cover everyone with household incomes up to 138 percent (133 percent, with a 5 percent income disregard) of poverty in every state.

But in 2012, the Supreme Court ruled that regular federal Medicaid funding could not be withheld from states if they opted not to expand their Medicaid programs. There are still 19 states that have taken no action towards expanding Medicaid, but unique approaches to expansion are gaining traction among the states that didn’t expand according to the provisions laid out in the ACA.

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.

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 August 2016, total enrollment in Medicaid/CHIP in New Hampshire increased by 58,685 people – a 46 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 6.3 percent by 2015 – a 41 percent decrease.

Medicaid expansion in New Hampshire was quite contentious, but 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 all Medicaid expansion enrollees to private coverage obtained through the exchange, utilizing Medicaid funding to subsidize the cost of the plans. This approach 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.

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

The future of Medicaid expansion in New Hampshire

Governor Hassan is not seeking reelection to the governor’s office, as she’s running instead for the U.S. Senate. Hassan is challenging incumbent Kelly Ayotte, who opposes the ACA and Medicaid expansion.

The Hassan-Ayotte race is very tight, although Hassan appears to have a small lead with two months remaining before the election.

Since Hassan is not seeking the governor’s office again, another tight race is underway to find her replacement. There will be a primary in mid-September, and 14 candidates are vying for the job. Hassan has been instrumental in expanding Medicaid in New Hampshire, and working to ensure continued funding. The new governor could have a significant impact on the future of Medicaid expansion in the state, depending on whether he or she supports or opposes the program.

New Hampshire Medicaid

How to apply

You can apply through 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.

Who is eligible

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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