Health insurance in New Hampshire
- New Hampshire utilizes a partnership exchange with enrollment through HealthCare.gov.
- Open enrollment for 2019 coverage in New Hampshire ended on December 15, but enrollment is still possible for residents who have qualifying events.
- Short-term health plans are available in New Hampshire with initial plan terms up to six months.
- Three insurers are offering 2019 coverage in New Hampshire’s individual market.
- 2019 premiums – on average – are lower than for 2018.
- About 50,000 New Hampshire residents enrolled in 2018 coverage through the state exchange.
- New Hampshire utilized a waiver to implement its own version of Medicaid expansion.
- Both of the New Hampshire CO-OPs have stopped offering coverage.
- In New Hampshire, short-term plan duration is limited to six months with no renewal.
New Hampshire’s health insurance marketplace
New Hampshire’s partnership exchange relies on the federal platform – HealthCare.gov – for application and enrollment, but the state operates Covering New Hampshire, which serves as a resource for those who purchase health insurance in the individual market.
Open enrollment for 2019 coverage ended on December 15, but enrollment is still possible for residents who have qualifying events.
- Ambetter: average decrease of 15.2 percent
- Anthem: average decrease of 13.5 percent
- Harvard Pilgrim: average decrease of 7.4 percent
New Hampshire enrollment in qualified health plans
In late 2013, the Kaiser Family Foundation estimated that the potential market for New Hampshire’s health insurance exchange was 137,000 people and that about 81,000 of them would qualify for premium subsidies. By June 2015, nearly 45,000 people were enrolled in qualified health plans (QHPs) through the state’s exchange, and nearly 63 percent of them were receiving premium subsidies.
The New Hampshire exchange had just one carrier – Anthem Blue Cross Blue Shield – in 2014. Anthem had 90 percent of the market share in the state prior to 2014, so the fact that only one carrier participated in the first year didn’t substantially change things for most customers in New Hampshire.
But starting in 2015, there was far more competition and plan choice in the New Hampshire exchange, with five carriers participating in the exchange in both 2015 and 2016. That had dropped to three insurers by 2018, as both of the CO-OPs have stopped offering coverage in the state.
New Hampshire uses Medicaid funds to purchase private plans in the exchange for the Medicaid expansion population, though the Premium Assistance Program (PAP). At the end of 2018 open enrollment, 49,573 New Hampshire residents had enrolled in coverage through the exchange – down about 6.5 percent from the previous OEP. Another 42,189 were enrolled in non-PAP private plans.
Read more about the New Hampshire health insurance marketplace.
New Hampshire Medicaid expansion
New Hampshire expanded Medicaid in 2014, but used an 1115 waiver to allow for a different approach to Medicaid expansion than the one outlined in the ACA. Senate Bill 413 was signed into law by Governor Hassan in March 2014, and called for Medicaid expansion to begin that summer, with residents able to begin applying on July 1.
The Kaiser Family Foundation estimated that about 39 percent of the uninsured population in New Hampshire would be eligible for Medicaid starting in July 2014. The coverage gap in New Hampshire was eliminated once the state became the 26th to expand Medicaid under the ACA.
As of August 8, 2014, the state reported that 9,399 people had enrolled in expanded Medicaid in the preceding five-and-a-half weeks, with coverage set to go into effect on August 15. That number was significantly more than the 7,235 people who had enrolled in Medicaid through the New Hampshire exchange by mid-April, before the expanded eligibility guidelines went into effect.
By August 2015, total New Hampshire Medicaid/CHIP enrollment had grown 47 percent since 2013 – the 12th biggest change nationwide. Enrollment largely plateaued after that, with net enrollment growth 45 percent higher in early 2018 than it had been in late 2013.
Until the end of 2015, Medicaid expansion in New Hampshire was following the program outlined in the ACA, and all legal residents with household incomes up to 138 percent of poverty were eligible to receive Medicaid coverage.
But starting in January 2016, the state transitioned to a privatized version of Medicaid expansion (i.e., Premium Assistance Program), using Medicaid funds to subsidize private coverage. By 2018, PAP membership hovered around 40,000 people.
In 2018, however, New Hampshire opted to abandon the PAP approach and move to a traditional Medicaid managed care system for Medicaid expansion enrollees. The state received federal permission to implement the Granite Advantage Health Care Program in January 2019, and also received separate federal permission to implement a Medicaid work requirement (the work requirement took effect in January 2019, but has been challenged in court). So New Hampshire no longer purchases private plans in the exchange for Medicaid expansion enrollees; they are enrolled in the Granite Advantage Health Care Program instead.
Read more about Medicaid expansion in New Hampshire.
New Hampshire CO-OP failures
Both of the CO-OPs that offered plans in New Hampshire have stopped doing so: Community Health Options left at the end of 2016, to focus entirely on the Maine market.
The state’s other CO-OP, Minuteman Health, continued to offer plans through New Hampshire’s exchange in 2017, but was placed in receivership that year and did not offer plans for 2018.
Read more about ACA’s CO-OP health plans.
Short-term health insurance in New Hampshire
New Hampshire has state regulations pertaining to short-term health insurance that limit short-term plan duration to six months with no renewal. (Enrollees are allowed to apply for a new short-term plan that takes effect after the first plan ends, but it has to be a new, separate plan, with a new deductible and out-of-pocket exposure.
But a short-term plan cannot be issued to anyone who has had more than 540 days of short-term coverage in the past two years. So a person can’t have more than a year and a half of short-term coverage in a given two-year period.
Read more about short-term health insurance in New Hampshire.
New Hampshire health ratings
In 2018, New Hampshire was ranked 11th out of the 50 states and the District of Columbia by The Commonwealth Fund’s Scorecard on State Health System Performance. The state performed in the top ten for two out of five measures: Access & Affordability, and Prevention & Treatment. But it ranked 35th for the Disparity metric.
New Hampshire’s scorecard provides more specific details about public health in the state and how the overall score was determined.
New Hampshire took 8th place in the 2017 edition of America’s Health Rankings (out of the 50 states and not including DC). The state ranked in the top spot for the Community & Environment metric, 5th place for Clinical Care, and 7th place for Policy. It came in 20th place for both Behaviors and Health Outcomes. The Rankings note that “New Hampshire has the lowest infant mortality rate in the U.S. at 4.2 deaths per 1,000 live births, and yet if it were an OECD country, it would rank No. 28 [out of 34 countries] and be tied with Hungary.”
Trust for America’s Health provides yet another look at overall public health in New Hampshire in their 2017 listing of Key Health Data About New Hampshire. Their summary includes socioeconomic health indicators, access to care, and the prevalence of various illnesses and health outcome predictors.
You can also see how the ten counties in New Hampshire compare with one another in terms of health factors and outcomes, using this interactive map created by the Robert Wood Johnson Foundation. No single area of the state stands out as better or worse than any other; high and low ranking counties are dispersed throughout the state.
New Hampshire and the Affordable Care Act
In 2010, New Hampshire’s U.S. Senators were split on the ACA. Democrat Jeanne Shaheen voted yes, while Republican Judd Gregg voted no. In the U.S. House, Carol Shea-Porter and Paul Hodes, both Democrats, voted yes.
Shaheen is still in the Senate, but Gregg was subsequently replaced by Kelly Ayotte, a fellow ACA opponent, who was in office until 2017. Ayotte was replaced in 2017 by Maggie Hassan, former governor of New Hampshire and a supporter of the ACA. In the House, Ann Kuster replaced Hodes in 2013. She is an ACA supporter who wants to keep the law but improve upon it.
In the 2014 Senate race, Shaheen was one of relatively few Democrats who fully embraced the ACA and the changes it has brought about. She defended the law, saying it was “absolutely” an achievement of which she is proud. Shaheen won re-election against Republican opponent Scott Brown in 2014. And Hassan defeated Ayotte in the 2016 election, with support for the ACA and New Hampshire’s Medicaid expansion included in her platform.
At the state level, the legislature is dominated by Republicans, with a Republican majority in both the Senate and the House. Governor Chris Sununu, who replaced Hassan in 2017, is a Republican, but has a more measured approach to the ACA than many in the GOP. Sununu would prefer that the federal government give states more latitude in designing their own health care regulations, but he was opposed to Senate Republicans’ 2017 effort to repeal the ACA, particularly the Medicaid funding cuts that would have been part of that legislation. Sununu also asked the Trump Administration to take action to help stabilize the individual insurance markets in 2017.
As governor, Hassan prevailed in expanding Medicaid under the ACA, although New Hampshire is one of five states utilizing a unique approach to Medicaid expansion that involves subsidizing private health insurance for low-income residents. But lawmakers in New Hampshire are considering a switch to regular Medicaid managed care instead. Arkansas also uses a privatized approach to Medicaid expansion, but Iowa announced in July 2015 that they would switch from buying private plans for Medicaid beneficiaries to a more standard approach to Medicaid expansion as of January 2016.
How has Obamacare helped New Hampshire residents?
New Hampshire operates a state-partnership exchange and expanded Medicaid, both typical of states that have embraced the Affordable Care Act. New Hampshire expanded Medicaid as of July 2014 — six months after expansion became available in many other states, but well ahead of numerous other states, many of which still have not expanded Medicaid as of 2018.
According to U.S. Census data, the uninsured rate in New Hampshire was 10.7 percent in 2013, which was well below the national average of 14.5 percent at that point. By 2016, the uninsured rate in New Hampshire stood at 5.9 percent – still well below the U.S. average of 8.6 percent.
Medicaid expansion has made coverage available for people earning up to 138 percent of the poverty level (about $16,753 for a single person in 2018). Additionally, the New Hampshire exchange makes affordable coverage available to people earning up to 400 percent of the poverty level ($48,240 for a single person in 2018; the 2017 poverty level guidelines are used in 2018, as it’s always based on the poverty level numbers for the year prior to the coverage effective date).
Young adults can remain on their parents’ health plans until age 26 as a result of the ACA, and health insurance companies no longer base eligibility or premiums on applicants’ medical history.
Does New Hampshire have a high-risk pool?
Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including New Hampshire. This meant that pre-existing conditions could result in an applicant being rejected for coverage, or offered a plan with significantly higher premiums or policy exclusions. The New Hampshire Health Plan (NHHP) was created in 2002 to provide an alternative for residents with pre-existing conditions who were not eligible to purchase private individual health insurance because of their medical history.
But the ACA brought significant changes to the individual health insurance market, including a ban on medical underwriting; all policies are now guaranteed issue, in all states. This meant that high-risk pools are no longer necessary the way they once were, since applicants with pre-existing conditions now have the same insurance choices as the rest of the population.
NHHP was originally slated to cease operations at the end of 2013, but the troubled rollout of Healthcare.gov meant that many members were unable to purchase new coverage by the start of 2014. As a result, NHHP continued to provide coverage until June 30, 2014. At that point, any remaining policies terminated, giving members a 60-day special enrollment period during which they could purchase a new plan (involuntary loss of other coverage is a qualifying event that triggers a special enrollment period).
Medicare enrollment in New Hampshire
New Hampshire Medicare enrollment reached 266,210 in 2015, nearly 20 percent of the state’s population compared with 17 percent of the total U.S. population enrolled in Medicare. New Hampshire is tied with six states for the highest percentage of population enrolled in Medicare.
As of 2013, the percentage of New Hampshire Medicare enrollees who qualified based on age alone was 82. The balance was eligible for Medicare as a result of a disability.
New Hampshire ranked 40th in terms of overall Medicare spending with $1.9 billion per year in 2009. Annually, Medicare spends about $7,602 per enrollee in the state compared with an average of $8,970 nationwide.
New Hampshire Medicare recipients can select a Medicare Advantage plan instead of original Medicare if they wish to gain some additional benefits. Only 7 percent of New Hampshire beneficiaries choose Medicare Advantage instead of traditional Medicare coverage in 2015, but that had grown to 10 percent by 2017. Only three states, Wyoming, Vermont, and Alaska, have a smaller population enrolled in Medicare Advantage.
Fifty-seven percent of New Hampshire Medicare recipients are enrolled in Medicare Part D plans, which provide stand-alone prescription drug coverage. Forty-four percent of all Medicare enrollees have Medicare Part D plans, but Medicare Part D is designed to work with Original Medicare, rather than Medicare Advantage (most Medicare Advantage plans have built-in Part D coverage). So a state like New Hampshire, with lower-than-average Medicare Advantage enrollment, would be expected to also have higher-than-average Medicare Part D enrollment.
State-based health reform legislation
S.B.313, under consideration in New Hampshire in 2018, calls for restructuring the state’s Medicaid expansion program to use Medicaid managed care – as most of the country does – instead of the Premium Assistance Program.
The new program would be called the New Hampshire Granite Advantage Health Care Program, replacing the current New Hampshire Health Protection Program. The legislation also calls for a work requirement for Medicaid, although in May 2018 CMS approved a work requirement that the state had proposed in late 2017; it will take effect in 2019.
Scroll to the bottom of the page for a summary of other recent health reform-related bills in New Hampshire.
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.