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Granite Advantage Health Care Program
Section 1115(a) Demonstration Waiver

July 9, 2018

Waiver Application Submitted to Fiscal Committee for July 20th Meeting

In accordance with the provisions of Senate Bill 313, which the Governor signed into law on June 29, 2018, the Department has prepared a waiver application and related State Plan Amendments for submission by the Governor to the Centers for Medicare and Medicaid Services. The legislation directs that the waiver and associated State Plan Amendments (SPAs) be presented to the Fiscal Committee prior to submission to CMS.

The Department considered public comments provided during the State public comment period, which ended on June 29th and submitted the following materials are related to Granite Advantage and were submitted to the Fiscal Committee on July 9, 2018:

Following the Fiscal Committee’s review, the Granite Advantage application will be submitted to CMS, whereupon CMS will initiate a 30-day public comment period.

Additional information will be available on the CMS website.



July 9, 2018

Revised Waiver Application

Summary of Current Demonstration

To date, New Hampshire’s Health Protection Program (NHHPP) Premium Assistance demonstration has used premium assistance to support the purchase of health insurance coverage offered by qualified health plans (QHPs) participating in the Marketplace’s individual market, for beneficiaries eligible under the new Medicaid adult group. The demonstration affects individuals in the Medicaid new adult, or expansion group, covered under Title XIX of the Social Security Act who are adults, aged 19 up to and including 64 years, with incomes up to and including 133 percent of the federal poverty level (FPL) who are neither enrolled in nor eligible for Medicare nor enrolled in the State’s Health Insurance Premium Payment (HIPP) program. Authority for the current Medicaid expansion expires on December 31, 2018.

On October 24, 2017, New Hampshire submitted an application to the Centers for Medicare & Medicaid Services (CMS) to amend the NHHPP demonstration in order to promote work and community engagement opportunities for Premium Assistance Program (PAP) participants. That request was approved by CMS on May 7, 2018. The new Granite Advantage Health Care Program (described below) would extend these work and community engagement requirements, with modifications, throughout the demonstration renewal period.

On May 7, 2018, the Centers for Medicare & Medicaid Services (CMS) approved New Hampshire's request for an amendment to its section 1115 demonstration project, entitled "New Hampshire Health Protection Program Premium Assistance" (Project Number l l-W-00298/1) in accordance with section 1115(a) of the Social Security Act (the Act).

Summary of Proposed Amendment and Extension

To continue to provide coverage for the Medicaid expansion population, and in accordance with legislation passed by the State Legislature, New Hampshire is seeking to amend and extend its current expansion waiver. Read the SB 313 legislation.

This amendment and extension will create the new Granite Advantage Health Care Program. Granite Advantage Health Care Program will: (1) sunset the NHHPP premium assistance program and instead provide Medicaid to expansion individuals through the State’s Medicaid managed care network, streamlining Medicaid program administration; (2) continue to apply work and community engagement requirements to the expansion population; (3) provide Medicaid eligibility to expansion individuals on the date all Medicaid eligibility requirements are met (i.e., usually the date of application), rather than three months of retroactive eligibility, without condition; and (4) incentivize beneficiary engagement in wellness activities and appropriate use of care.

In addition, in accordance with legislative direction, the State is seeking to implement the following features as part of Granite Advantage Health Care Program, to the extent permitted by federal law:

  • Modify eligibility such that a participant cannot be eligible for coverage unless such person verifies his or her United States citizenship by two forms of identification and proof of New Hampshire residency by either a New Hampshire driver’s license or a non-driver’s picture identification card.
  • If allowed by federal law, apply an asset test when determining eligibility for members of the Medicaid expansion population.

Historically, New Hampshire spent $394 million in calendar year (CY) 2016 and $434 million in CY 2017 on the NHHPP population receiving services through the demonstration. CY 2018 spending is projected to be $535 million. Over time, costs have increased as enrollment in the program has grown and as the cost of providing premium assistance through QHPs increased. During negotiation over Senate Bill 313—the legislation that authorizes Granite Advantage—New Hampshire estimated that program spending would be $171 million over the first six months of the demonstration period. New Hampshire anticipates that spending growth in the future will be consistent with standard growth rates experienced in the past, ranging from the 3.7% trend rate described above to the 4.9% President’s budget trend rate. Therefore, New Hampshire estimates that annual program spending will range from $354.8 million to $398.1 million over the extended 5-year demonstration period.

These changes reflect savings from enrolling the demonstration population in Medicaid managed care as well as other features of Granite Advantage that will incentivize beneficiary engagement in wellness initiatives and appropriate levels of care and continue to emphasize personal responsibility. Projected spending accounts for the Medicaid expansion adults currently enrolled in the PAP as well as medically frail expansion adults. Spending estimates also account for other features of Granite Advantage, including new work and community engagement requirements as well as the requested waiver of retroactive coverage, which is predicted to reduce churn in and out of the program. DHHS is continuing to analyze the anticipated budgetary impact of such changes.

Eligibility for the Granite Advantage population is based on the Medicaid State Plan, which also provides authority to enroll Medicaid beneficiaries in the state’s Medicaid managed care program. All expenditures for the program are therefore authorized by the State Plan and State Plan spending is not subject to budget neutrality requirements. New Hampshire will continue to monitor program spending in accordance with Senate Bill 313 to assure alignment with the Granite Advantage budget.

Demonstration Objectives, Hypotheses and Evaluation Plan

The extended and amended demonstration will further the objectives of Title XIX of the Social Security Act by making a number of changes to improve beneficiary health. By promoting efficiencies that ensure Medicaid’s sustainability for beneficiaries over the long term, by strengthening beneficiary engagement in their health care coverage, care and outcomes, and by aligning Medicaid and commercial plan policies relating to retroactive coverage, the demonstration will promote the health of the Granite Advantage demonstration population. In addition, by transitioning individuals from premium assistance for Marketplace coverage to the State’s Medicaid managed care delivery system will enable New Hampshire to realize program administration efficiencies and continue offering expanded coverage to low-income residents, reduce uncompensated care, better combat the opioid and substance use disorder crisis, and improve the State’s workforce. Granite Advantage will incentivize beneficiary engagement in wellness initiatives and appropriate levels of care and continue to emphasize personal responsibility through CMS-approved work and community engagement requirements. All of these changes will support the State’s ultimate objective of improving beneficiary health.

Over the course of the Demonstration extension period, New Hampshire will continue to evaluate the Granite Advantage Health Care Program. Per recently enacted State legislation, the Granite Advantage program will be evaluated on an annual basis, using an outcome-based evaluation methodology, with the following goals in mind: providing accountability to beneficiaries and the overall program; determining whether beneficiaries are making informed decisions in carrying out health care choices and utilizing the most appropriate level of care; and analyzing whether the use of incentives and cost transparency efforts is effective at lowering costs while maintaining quality and access. The evaluation results will be included in a report that is submitted to CMS, the president of the State senate, the speaker of the State house, the governor, and the legislative fiscal committee by December 31 each year, beginning in 2019.

Over the course of the demonstration extension period, New Hampshire will test the following hypotheses and evaluate the Granite Advantage Health Care Program accordingly. Details about the hypotheses and evaluation parameters follow:

Hypothesis Evaluation Approach Data Sources
1. Members enrolled in the demonstration who are subject to community engagement requirements will have positive health outcomes. Analyze Medicaid disease prevalence and Medicaid and former Medicaid self-reported health status Encounter data (Medicaid covered), Evaluation survey (both Medicaid covered and former Medicaid)
2. Members enrolled in the demonstration who are subject to community engagement requirements will obtain sustained part-time and full-time employment. Analyze Medicaid reported employment and Medicaid closure reasons Medicaid enrollment system data
3. Members enrolled in the demonstration who are subject to community engagement requirements will gain access to employer-sponsored and individual market coverage. Analyze Medicaid and former Medicaid member self-reported insurance coverage Evaluation survey (both Medicaid covered and former Medicaid)
4. Eliminating retroactive coverage will encourage beneficiaries to obtain and maintain coverage, even when they are healthy, without negatively impacting churn in and out of the program. Analyze Medicaid months of gaps in coverage Medicaid enrollment system data

Upon approval of this amendment and extension, the State will work with CMS to develop an evaluation design plan consistent with the approved demonstration and CMS policy.

Waiver Authorities

As part of this amendment and extension, New Hampshire is requesting the following federal waivers:

  • That CMS waive Section 1902(a)(34) of the Social Security Act to permit the State to provide coverage to Granite Advantage applicants beginning on the date of the application; coverage would be effective no earlier than the day all eligibility requirements are met, if all eligibility requirements are met on that date.
  • That CMS continue, for the upcoming five-year demonstration period, to grant the State authority to condition Medicaid eligibility on completion of work and community engagement activities. The State is therefore seeking to extend waivers of Sections 1902(a)(8) and 1902(a)(10) to the extent necessary to enable New Hampshire to suspend or terminate eligibility for, and not make medical assistance available to, Granite Advantage beneficiaries who fail to comply with work and community engagement requirements, as described in the approved demonstration Special Terms and Conditions (STCs), unless the beneficiary is exempted or obtains a good cause exemption, as described in the STCs. The State is also seek to extend its waiver of Section 1902(a)(10) to the extent necessary to enable New Hampshire to require community engagement as a condition of eligibility as described in the approved STCs.
  • To the extent permissible by federal law, that CMS waive Section 1902(a)(46)(B) insofar as it incorporates 42 CFR 435.407 and 435.956 to permit the State to require paper forms of identification rather than rely on electronic database matching to establish citizenship or residency. The waiver authority will allow the State to deny eligibility to applicants who are unable to verify their United States citizenship through two forms of identification or unable to prove New Hampshire residency through either a New Hampshire driver’s license or a non- driver’s picture identification card, as required by State legislation.
  • To the extent permissible by federal law, that CMS waive Section 1902(e)(14) to permit the State to consider assets when determining Medicaid eligibility. The waiver authority will enable the State to consider assets when determining eligibility of Granite Advantage members.

In addition, New Hampshire will work with CMS to eliminate authorities that were unique to the premium assistance program and are no longer required to operate the Granite Advantage Health Care Program. For example, authority to vary cost-sharing for the premium assistance population will be eliminated.

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