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Confusing Letters, Frustrated Members: N.H.'s Medicaid Work Requirement Takes Effect

Sara Plourde / NHPR

As a new work requirement for beneficiaries of New Hampshire’s expanded Medicaid program takes effect this month, some in the healthcare industry say early signs are pointing to a bumpy road ahead.

Staff at community health centers and attorneys working with Medicaid beneficiaries say many people appear overwhelmed by the new rules, exemptions, and forms that are needed to comply with the new work requirement, also called a "community engagement requirement." They describe clients frustrated by the multiple letters and automated phone calls from the state health department designed to educate Medicaid beneficiaries about a significant change to the program.

Some fear it is the first sign of a difficult roll out for the work requirement, which applies to roughly 28,000 people this month.


“We’re just heading into this storm,” says Bob MacLeod, CEO of Mid-State Health Center, “and what we’re seeing right now doesn’t bode well for the future.”

June marks the first month that some people on New Hampshire's Medicaid expansion will need to prove they are completing 100 hours of work or other qualifying activities, or provide proof that they should be exempt from the requirement. If they don’t, they risk losing their health insurance by as early as this August.

Sara Plourde

In preparation for the rollout of the new rules, the Department of Health and Human Services began a large public information campaign, placing thousands of robocalls and mailing thousands of letters to Medicaid recipients who will be affected by the change.

Staff at multiple community health centers spoke highly of the efforts by the state health department officials to educate Medicaid expansion recipients and for being available to answer case-by-case questions when needed.

But those same staff also reported a general sense of confusion and frustration among Medicaid recipients who are subject to the requirement.

“A lot of people are telling us that it’s so difficult, at least from their perspective, that they just simply are saying, ‘We’re dropping out, we can’t deal with this, it’s too complicated,’ ” says MacLeod.

The Department of Health and Human Services was unable to provide anyone for comment for this story by deadline.

Confusing Letters

NHPR contacted several community health centers and spoke with legal advocates who work closely with those who fall under Medicaid’s new work requirements. Many of them shared anecdotes of Medicaid beneficiaries who were confused by the letters and automated phone calls sent out by the health department.

In at least one case, a Medicaid recipient received conflicting notices as to her exemption status under the new requirement. The recipient, who wished to remain anonymous, shared her documents with NHPR through her legal counsel at New Hampshire Legal Assistance.

The Medicaid recipient was informed in February she was exempt from the work requirement due to her status as a SNAP recipient (Supplemental Nutrition Assistance Program).


In early March, a second letter told her that to be exempt, she needed a doctor’s note to prove her status as medically frail -- something she had previously indicated to DHHS. The letter stated her status is “mandatory until we get your signed medical frailty form.”



A few weeks later, on March 29, a new letter stated she is exempt due to medical frailty and listed an “exemption end date” of March 31, 2020.


Three days later, another letter told her she is “voluntary for community engagement,” meaning she can choose to participate by reporting her work hours each month to the Department of Health and Human Services. According to her lawyer, the woman requested no such change.


On May 1st, a new letter again stated she is exempt due to medical frailty, listing the same “exemption end date” of March 31, 2020.


Then on May 24th, a new letter suggested her exemption status is now in question. It stateed state health officials did not receive the exemption form needed to determine her medical frailty status -- despite having informed her twice that she had been granted exemption status due to medical frailty.


As of this writing, the Medicaid recipient and her legal counsel at New Hampshire Legal Assistance, Raymond Burke, are not sure whether she is subject to the new work requirement.

Burke says her case is a warning sign for others to come.

“In taking a look at the notices she received, you can get a sense of how confusing the process can be for our clients and how difficult it could be for them to try to comply,” said Burke.

Lingering Questions

Whether cases like this are widespread or just isolated kinks being worked out of a new system will become clearer in July when the health department announces how many Medicaid expansion beneficiaries complied with the work requirement so far.

At the State House, a Democrat-backed bill designed to limit the number of people who lose health insurance due to the work requirement could soon be before Gov. Chris Sununu. The bill, currently being negotiated by legislators, would add exemptions to the work requirement and provide an automatic shut-off provision if more than 500 people lose their Medicaid coverage because of the requirement.

Meanwhile, a class-action lawsuit against New Hampshire’s work requirement in federal court could soon put the new rules on pause. A ruling in the case could come as early as next month.


Jason Moon is a senior reporter and producer on the Document team. He has created longform narrative podcast series on topics ranging from unsolved murders, to presidential elections, to secret lists of police officers.
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