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Digital journalist Brian Wallstin and NHPR's News and Digital team explain the issues, timelines and facts behind the news.

NHPR News Primer: The Latest Medicaid Expansion Plan

Sara Plourde

Full details of a Senate plan to expand Medicaid under the Affordable Care Act are out.

(If you are brave, you can read the bill here.)

Let’s take a stab at simplifying the proposal:


Individuals who make less than 138% of the federal poverty level, or roughly $16,000 a year, could get health coverage through Medicaid starting July 1st. (The income threshold is higherfor families.) Estimates vary, but in New Hampshire we are talking somewhere around 40,000-50,000 people.

These new enrollees would select from one of three Medicaid managed care companies, called MCOs. The state has contracts with these private organizations, which basically manage administration and function like other insurance carriers.


Starting in January, 2016, all those new enrollees would transition into the exchange ( to select their preferred coverage plan. The federal government would still pay for everything, but this system, in theory, provides more choice for people. Hospitals and doctors like it, too, because their reimbursement rates are usually higher with private insurance.

New Hampshire lawmakers call this part of expansion the ‘premium assistance program’.


Ah yes, HIPP, the Health Insurance Premium Payment program. HIPP already exists in New Hampshire, but is rarely used despite its costs savings.

It works like this: anyone who qualifies for Medicaid but already gets insurance through a job (or a spouse’s) stays on that private insurance. Medicaid picks up the costs for any out-of-pocket expenses, including a worker’s share of the premiums, as well as deductibles and co-pays.

In New Hampshire right now, HIPP is voluntary, meaning people can just hop onto Medicaid and ditch the employer-sponsored insurance if they want. But under the proposed expansion plan, anyone eligible for employer-sponsored private coverage would be mandated to stay in that private coverage.

We’re talking roughly 12,000 or so people.


Yes, this entire plan ends December 31, 2016, which is also the day the federal government no longer funds the expansion at a full 100% of costs.

Future lawmakers would have to renew or revise the plan, or perhaps come up with an entirely new system.


First, a promise from the federal government. If it fails to pay for 100% of costs through 2016 as outlined in the Affordable Care Act, New Hampshire immediately repeals the expansion plan.

Second, if the federal government doesn’t give its permission for the proposed ‘premium assistance program,’ the state cancels Medicaid coverage for newly eligible recipients as of June 30, 2015.

The feds get until March 31, 2015 to decide if they like the proposed plan. One key measure they’ll look at is if this entire package actually lowers costs. If it doesn’t, expect a rejection letter.


The state needs permission from the feds to implement the private insurance option for Medicaid.

But in a push to further reform the entire Medicaid system in New Hampshire, there are other waivers written into the bill. They are called 1115 Demonstration Waivers, and they have the potential to dramatically change how Medicaid provides and pays for health insurance. Senate Majority Leader Jeb Bradley (R-Wolfeboro) says an 1115 waiver could save the state tens of millions of dollars in the future by reforming how services like mental health and inmate health care get paid for.


Both Republicans and Democrats in the Senate say they are behind the plan, so it may see little resistance. House Democrats are also likely to back the idea, and Governor Hassan has said she is on board. 

But compromises on expansion have come close in the past--most recently last November during a special legislative session--so nobody is counting on this as a done deal yet. And then of course, the feds need to give the okay.

Todd started as a news correspondent with NHPR in 2009. He spent nearly a decade in the non-profit world, working with international development agencies and anti-poverty groups. He holds a master’s degree in public administration from Columbia University.
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