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

May 8, 2018
Notice is hereby given that the New Hampshire Department of Health and Human Services (DHHS) is seeking to amend and extend for five years its Medicaid Section 1115(a) Research and Demonstration Waiver, #11-W-00298/W, to continue the State’s efforts to integrate cost control and personal responsibility into the State’s Medicaid program. As described below, New Hampshire is convening two public hearings and providing additional opportunities for public input on a Granite Advantage Health Care Program Section 1115(a) Demonstration Waiver that will enable New Hampshire to extend its Medicaid expansion program, effective January 1, 2019.

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).

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. 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.

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.

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 program. For example, authority to vary cost-sharing for the premium assistance population will be eliminated.

State Plan Amendment Public Comment

The State will also seek comment on its draft Alternative Benefit Plan (ABP) State Plan Amendment (SPA), pursuant to 42 CFR 440.386, during the waiver public comment period. The Department plans to amend the State Plan to provide the same benefits to the Granite Advantage Medicaid new adult group as is currently being provided to individuals enrolled in other eligibility categories. The cost sharing State Plan will also be amended to align copayments for the expansion population with those for other Medicaid categories. To learn more, view the ABP-SPA Public Notice Adobe Acrobat Reader Symbol.

Public Hearings

DHHS will host two public hearings during the public comment period at the following times and locations:

  • Monday, May 14, 2018 2:00-4:30 PM
    Department of Health and Human Services
    29 Hazen Drive, Auditorium
    Concord, NH
    Presentation materials will be available on this web site May 11, 2018
  • Thursday, May 24, 2018 5:30-8:00 PM
    Harbor Homes
    77 Northeastern Blvd
    Nashua, NH
    If unable to attend, you may call in to the May 24th hearing:
    • Toll Free Number: 1-866-304-8625
      When prompted, dial: 965 412 0884
      Presentation materials will be available on this web site May 23, 2018

If accommodations are needed for communication access such as interpreters, CART (captioning), assistive listening devices, or other auxiliary aids and/or services, please contact Leslie Melby at Leslie.Melby@dhhs.nh.gov or 603-271-9074 no later than May 9, 2018 for the May 14th hearing, or May 17th for the May 24th hearing, in order to assure availability. Requests made later than these two dates will attempt to be accommodated but cannot be guaranteed.

Comments will also be considered at the Monday, May 14, 2018 Medical Care Advisory Committee Meeting, from 10-12 p.m. All Medical Care Advisory Committee Meetings are open to the public.

Medical Care Advisory Committee Meeting location:
NH Hospital Association
125 Airport Rd, Conference Room 1
Concord NH 03301

Public Comment

The 30-day public comment period for the Granite Advantage Health Care Program Section 1115(a) Demonstration Waiver is from May 8, 2018 until June 7, 2018. All comments must be received by 5:00 PM (Eastern Time) on June 7, 2018.

DHHS would like to hear your comments about the changes it is proposing. After hearing the public’s ideas and comments about the proposed changes, DHHS will make final decisions about what changes to make to the Granite Advantage Health Care Program Section 1115(a) Demonstration Waiver and then submit a revised application to CMS. The summary of comments will be posted for public viewing on this web page along with the waiver renewal application when it is submitted to CMS.

There are several ways to give your comments to DHHS. One way is to attend the two public hearings held at the dates/locations noted above, or the Medical Care Advisory Committee Meeting, also noted above. At the public hearings, you can give verbal or written comments to DHHS. Additional information about providing comments is noted below.

Additional Information
Requests for a hard copy of the Granite Advantage Health Care Program 1115(a) Demonstration Waiver application should be submitted by mail to:

Leslie Melby
New Hampshire Department of Health and Human Services
Attn: Granite Advantage Health Care Program Section 1115(a) Demonstration Waiver
129 Pleasant Street
Concord, NH 03301

A hard copy of the Granite Advantage Health Care Program 1115(a) Demonstration Waiver application can also be picked up at DHHS, which is located at:

New Hampshire Department of Health and Human Services
Fred H. Brown Building
129 Pleasant Street
Concord, NH 03301

Another way to provide your comments is by emailing comments to nhmedicaidcaremanagement@dhhs.nh.gov or mailing written comments to the address above. When mailing or emailing please specify the Granite Advantage Health Care Program Section 1115(a) Demonstration Waiver.

All information regarding the Granite Advantage Health Care Program Waiver can be found on this web page. DHHS will update this website throughout the public comment and application process.

 

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