New Hampshire Medicaid- A Primer for Home Care Providers

The Medicaid program is the largest health insurance program in the U.S., covering millions of the poorest individuals and families in the nation. As such, Medicaid is also a key source of health care financing. Medicaid covers many people with disabilities and complex needs, and the program has been an important locus of innovation and improvement in health care delivery and payment. The Affordable Care Act (ACA) expanded Medicaid significantly beginning in 2014.

Who Does Medicaid Cover?

Medicaid covers more than 62 million people, or 1 in 5 Americans. It covers more 1 in 3 children and some of their parents, and 40% of all births. It also covers millions of people with severe disabilities, and provides extra assistance to poor Medicare beneficiaries. Historically, the program has excluded most non-elderly adults, but the ACA expanded Medicaid beginning in 2014, making it broadly a program for people under age 65 with income at or below 138% of the federal poverty level. Each state will decide whether to adopt the Medicaid expansion.

What Does Medicaid Cover?

Medicaid covers a wide spectrum of services to meet its beneficiaries’ diverse needs.  Medicaid benefits for children are uniquely comprehensive; adult benefits vary significantly by state. Medicaid covers many long-term services and supports that private coverage and Medicare exclude or limit, as well as services like non-emergency transportation and translation services that improve access for low-income people. The ACA established new minimum standards for the Medicaid benefits that most adults who gain Medicaid due to the ACA expansion will receive.

How is Medicaid Financed?

Medicaid is financed jointly by the federal government and the states. The federal
government matches state Medicaid spending. The federal math rate varies across states based on a formula and ranges from a minimum of 50% to much higher levels in poorer states.  Medicaid is a counter cyclical programs that expands during economic downturns when state’s fiscal capacity is also most strained.
States and the federal government jointly finance the Medicaid program. The Centers for Medicare andMedicaid Services (CMS) oversee all state Medicaid plans. A Medicaid
“State Plan”is the contract between that state and the federal government that determines which services are covered and how much each entity will pay for the program. All state plans cover certain mandatory benefits as determined by federal statute. States and CMS can also agree to cover additional benefits designated as ‘optional’ in federal statute.
For example, Medicaid’s rehabilitative services option is an optional benefit that states use  to cover a fairly broad range of recovery-oriented mental health and substance use disorder services.  For CMS to approve optional benefits, states must meet CMS rules. For the rehabilitation option, the service must meet the purposes of “reducing disability and restoring function.”
States can also apply to CMS to amend or waive certain provisions in the state plan for specific populations by adopting state plan amendments and waivers. These authorities are commonly known by their federal statute section number. Some have particular applicability to supportive housing services.  1115 Medicaid waivers allow for state demonstration programs for new services, populations or payment structures. 1915 (c) Waivers and 1915 (i) state plan amendments help states target Home and Community Based Services (HCBS) for specific populations (seniors, individuals with severe or persistent mental illness, developmental disabilities, children with special health care needs, people living with traumatic brain injuries). These services are designed to serve people in their own homes and communities rather than in institutions.
Reimbursement for Medicaid services can be delivered in a variety of ways. States can reimburse providers directly for services or contract with managed care organizations (MCOs) to negotiate services and payment structures with providers. In some cases, MCOs also deliver services directly. States and For more detail on mandatory and optional Medicaid benefits.

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.

For Medicaid Providers In New Hampshire 

All providers of NH Medicaid covered services must be enrolled as a NH Medicaid provider with Xerox to bill medical or pharmacy claims for NH Medicaid recipients. You can contact Xerox via their website or call them at 1-866-291-1674 or (603) 223-4774 to become an enrolled provider.
If you have questions on if a NH Medicaid covered service requires a prior authorization (PA) please visit Xerox’s website and select downloads to obtain all prior authorization forms for services. 
If you have questions on prescription drug coverage and clinical prior authorizations please visit Magellan’s website at:
To check eligibility for a NH Medicaid recipient please call 1-866-291-1674 and follow the prompts. 


  • Betsy Hippensteel is the Medicaid Provider Relations Representative at NH DHHS.  She can help answer questions about Medicaid and CFI enrollment, and facilitate the process if you run into any difficulties.  She can be reached at 271-9414 or
  • Jane Hybsch is the Director of NH DHHS Medicaid Medical Services Unit.  She oversees Medicaid Private Duty Nursing, which is for patients who need more than 2 hours at a time of RN or LPN care.  Her phone number is 271-9423.  Her email is
  • Here are the rules for various Medicaid programs.  You need to scroll through the different sections:
    • He-W 540 is for Private Duty Nursing (you need to contract with Centene and Wellsense)
    • He-W 553 is for Medicaid Home Care (contract with Centene and Wellsense)
    • He-W 558 is for CFI