Medicaid is a state-federal fiscal partnership that provides public health coverage to eligible populations who may otherwise face barriers to accessing health care, including adults and children in households with low incomes, people with disabilities, pregnant mothers, and current and former foster youth. In New Hampshire, Medicaid services for most enrollees are coordinated through state-contracted managed care organizations (MCOs), including NH Healthy Families, WellSense Health Plan, and AmeriHealth Caritas New Hampshire. These three options provide enrollees with multiple pathways to accessing care.

The 2010 federal passage of the Patient Protection and Affordable Care Act (ACA) and subsequent 2014 Medicaid Expansion in New Hampshire significantly broadened eligibility for Medicaid coverage. Since 2019, Medicaid Expansion in New Hampshire has been implemented through the Granite Advantage Health Care Program, commonly known as “Granite Advantage.” The program extends Medicaid eligibility to adults age 19 to 64 with incomes up to 138% of the federal poverty guidelines, or $22,025 for a household of one in 2026.[1] Medicaid Expansion has been vital to reducing the state’s uninsured rate and uncompensated care costs, with New Hampshire’s uninsured rate declining by more than half following its implementation.

Medicaid has provided vital coverage for New Hampshire residents with limited resources, particularly those who are unable to obtain health insurance through work. Based on national data from 2023, nearly half (46%) of employed Medicaid enrollees worked for companies with fewer than 25 employees. These smaller companies are generally exempt from offering health coverage, even under ACA requirements, and are less likely to offer health insurance to their workers compared to larger companies that typically have more financial resources. Medicaid enrollees are also more likely to work in occupations that offer fewer opportunities for employer-sponsored health insurance, including in agriculture and service-based roles. In 2023, only around 41.4% of workers employed in agriculture occupations and 55.6% in service occupations were eligible for insurance through their employer.[2]

Several recent federal changes to Medicaid are expected to disproportionately impact the Granite Advantage population. Beginning next year, most Medicaid Expansion adults will face new federal work requirements that require enrollees to document 80 hours per month of work, community service, education, or some combination of eligible activities. Although around three-quarters of New Hampshire’s Medicaid population is already working, the new requirements and associated administrative burdens are expected to result in substantial coverage losses over time.

New federal Medicaid work requirements begin to take effect in January 2027 for enrollees who are up for coverage redetermination, but the federal government has given states significant discretion over how they implement them. New Hampshire has already chosen some policies that are stricter than the minimum requirements under federal law, while other important decisions remain in the months ahead. How the State implements these requirements could significantly affect how many Granite Advantage enrollees lose coverage. Depending on final decisions and the effectiveness of implementation, an estimated 23,000 to 29,000 fewer adults could be enrolled in the Granite Advantage program by 2028.

Medicaid Enrollment

Based on the U.S. Census Bureau’s population estimates from July 1, 2025, an average of about 13.0% of New Hampshire’s population was enrolled in Medicaid, similar to the 13.4% enrolled in 2024.[3] An average of 7.1% of adults ages 19-64 were enrolled in the State’s Medicaid Expansion program, with Granite Advantage adults representing around a third (31.6%) of the total average Medicaid enrollment in 2025.

An average of 33.9% of New Hampshire children under age 18 were enrolled in Medicaid, representing around 44.6% of the total average Medicaid enrollment in 2025. Medicaid provides health coverage for children in households with incomes up to 323% of the federal poverty guidelines, or $88,244 for a household of three in 2026.[4] Medicaid also provides coverage for children with disabilities, as well as children currently or formerly in the foster care system.

In 2025, approximately 75.2% of Medicaid participants who chose to disclose their race and ethnicity during enrollment or redetermination identified as white and non-Hispanic. Among those disclosing their race, around 10.4% identified with a race other than white, including Black or African American, Native American or Alaska Native, Native Hawaiian or Pacific Islander, or biracial or multiracial. Collected separately from race, about 8.1% identified as Hispanic or Latino.[5]

Enrollment by Municipality

Across New Hampshire, Medicaid enrollment varied by municipality and region. Eighty-eight municipalities had higher percentages of their populations enrolled in Medicaid than the statewide average of 13.0%. One in three (30.0%) Stratford residents were enrolled in coverage in 2025, a Coos County municipality with the highest percentage recorded across all municipalities in the state. More than a quarter of each municipality’s population was enrolled in coverage in Stewartstown (28.8%), Warren (27.3%), Claremont (26.4%), and Berlin (25.4%), two of which are located in Coos County, the northernmost part of the state.

Thirteen municipalities had less than 5% of their populations enrolled in Medicaid; ten of these 13 municipalities are located in the four southeasternmost counties of the state. Only 1.9% of New Castle’s population was enrolled in Medicaid, which was the lowest percentage in the state among organized municipalities with more than 100 residents. Relatively low percentages were also enrolled in the more populous communities of Hanover (2.1%) and Durham (2.3%).

Despite relatively lower percentages of their populations enrolled in Medicaid, the state’s four southeasternmost counties had larger counts of Medicaid enrollees due to their larger populations. Cities also had larger Medicaid enrollee populations, even when lower percentages of the population were enrolled. For example, 15,340 Nashua residents (16.6% of the population) were enrolled in Medicaid, compared to 194 in Stratford (30.0%). Despite higher enrollment counts in the state’s more populous communities, nearly three-quarters (72.5%) of Medicaid participants lived outside of the state’s three largest cities (Manchester, Nashua, Concord), and 59.4% outside of the ten largest municipalities (Dover, Derry, Rochester, Salem, Merrimack, Londonderry, Hudson).

While New Castle recorded lower enrollment, approximately 63.2% of the municipality’s Medicaid population received coverage through Granite Advantage, the highest percentage in the state. Granite Advantage adults also represented larger shares of the Medicaid population in Easton (54.5%), Acworth (53.4%), and Errol (51.4%).

Enrollment by State Legislative District

New Hampshire is organized into 24 State Senate Legislative Districts, with each municipality categorized into a district.[6] District 1, comprising Coos County and portions of Grafton County, had the largest share of Medicaid enrollment, with approximately one in five (19.6%) residents receiving this public health coverage. Only an average of 6.6% of District 24’s population, comprising most towns along the state’s coastline, was enrolled in the program, the lowest percentage in the state.

New Hampshire is organized into more than 200 State House Legislative Districts, with each municipality categorized into a district. An average of one in four (25.6%) residents in House District Sullivan 6, comprising Claremont and Croydon, were enrolled in Medicaid, the highest percentage in the state. House District Coos 5, comprising Berlin, and House District Cheshire 11, comprising Winchester, also had relatively high percentages, at 25.4% and 24.5%, respectively.

New Hampshire also has several State House Floterial Districts, which are used to distribute the remaining population that does not fall within other House districts. House District Coos 7, comprising residents of Berlin, Carroll, Jefferson, and Whitefield, had 22.7% of its residents receiving Medicaid coverage. Only an average of 2.8% of House District Rockingham 37’s population, comprising residents of New Castle and Newington, was enrolled in the program.

 

Declining Enrollment in 2026

While 2026 municipal-level data are not yet available for the full year, monthly caseload data shows declining enrollment over the past State Fiscal Year (SFY). As of August 31, 2026, a total of 166,807 Granite Staters were enrolled in Medicaid, a decline of 8.3% from the 181,872 enrolled during the same point in 2025. Granite Advantage enrollment declined by 15.4% during this period, with 47,984 adults enrolled in the most recent data.[7]

Declines in the Medicaid population over the past year are likely due to the return to pre-COVID-19 pandemic regular eligibility redeterminations for Medicaid enrollees renewing their coverage, as required by the current 2026-2027 State Budget.[8] During the pandemic, the federal government permitted states to keep Medicaid enrollees continuously retained in coverage without having to redetermine each year. Upon the expiration of this provision in 2023, the federal government allowed states to adopt optional Medicaid section 1902(e)(14)(A) waivers to help with the return to redetermination processes and help lessen administrative burden on the State. These waivers included several strategies to help retain enrollees through ex parte or automatic renewal practices, as well as strategies to help reinstate coverage for individuals who were disenrolled due to procedural reasons.[9] As of December 2024, New Hampshire had four ex parte-related waivers in place; however, under the changes included in the current State Budget, all waivers were terminated and the State returned to pre-pandemic eligibility processes on July 1, 2025.[10]

These changes have made it harder for many Granite Staters to retain their coverage. Based on preliminary data from the first quarter of 2026, an average of 28.2% of enrollees up for redetermination lost coverage, a significant increase from the average of 10.6% during the same quarter in 2025. Most people who lost coverage did so for procedural reasons rather than because they were determined to be ineligible. Among those disenrolled, approximately 84.3% lost coverage for procedural reasons. Among those up for renewal, only 34.1% were retained through ex parte, down from 78.6% the prior year.[11]

Overview of Work Requirements

The 2025 federal reconciliation law, commonly known as the One Big Beautiful Big Act (OBBBA) or House Resolution 1 of 2025 (H.R. 1), introduced sweeping health policy changes to the Medicaid program, impacting enrollment requirements, coverage redeterminations, and funding mechanisms.[12] One of the largest changes impacting enrollment was the introduction of federal Medicaid work requirements. Under these changes, Medicaid Expansion adults ages 19 to 64 will be required to prove work compliance, engagement in an eligible community service activity, participation in an employment or educational program, or some combination of those activities for at least 80 hours per month.

Under the new federal law, enrollees will be required to meet the requirements for at least one month before enrolling in Medicaid and for at least one month during each six-month period, at which point coverage will be redetermined. However, state governments have the flexibility to increase the required number of months, and New Hampshire already made some of these decisions earlier this year.

Under H.R. 1, certain populations are exempt from meeting the new work requirements, including, but not limited to, parents or guardians of dependent children who are under 14 years old or who have a disability, individuals who are medically frail or have a disability that meets certain definitions, adults in households already complying with Supplemental Nutrition Assistance Program (SNAP) work requirements, and individuals who are pregnant or receiving postpartum care.

States are required to implement these new requirements by January 1, 2027, meaning that Medicaid applicants seeking coverage on or after that date will need to comply, while current enrollees will be subject to the requirement when they next renew their coverage. However, states can begin requirements before that date if they choose to. States can also apply for a good-faith exception or a temporary implementation extension if they demonstrate they are taking active steps toward implementation and are facing unexpected challenges. However, federal analysis of the rules implementing the work requirements forecasts that few exceptions will be approved under the strict guidelines; these federal estimates, associated with the rulemaking process, assume that ten states will apply, with only two states approved for a good-faith exception, and an extension period of only six months per approval.[13]

New Federal Guidance

In June 2026, the U.S. Centers for Medicare and Medicaid Services (CMS) released work requirement compliance and implementation guidance for states.[14] Although much of this guidance confirmed the language already outlined in the OBBBA, some adjustments and additions were made, particularly to exclusions and compliance measures.

Exclusions: The federal guidance created a more stringent medically frail definition, requiring that such conditions must “significantly impair” compliance with the work requirement; this language differs from traditional definitions used for alternative benefit plans (ABPs) and other assistance programs. States will be required to use diagnostic codes to identify conditions that meet the medically frail exclusion criteria, although coverage decisions are still required to be individualized if a person’s diagnosis is not included in the list of applicable conditions.

The guidance also sets requirements for caregiver exemptions, with parents and family caregivers required to meet one of three outlined criteria: co-residing caregivers, or those living with the care recipient and providing “regular” care that is not incidental (no minimum hourly tracking required); related non-residing caregivers, or those not living with the recipient but still providing regular care (no minimum hourly tracking required); or unrelated non-residing caregivers, who would be caregivers not living with or related to the recipient (must provide at least 80 hours of documented care per month).

The guidance also narrows exclusions for individuals with a substance use disorder and/or in treatment by allowing states to establish a minimum time commitment to qualify; under the guidance, this exclusion will also not be available after five years of “stable recovery,” which is loosely defined under the federal rule. In addition, states must also accept pregnant and postpartum status on application or renewal forms for those seeking an exemption; states are also encouraged to use claims data or other available data to identify pregnant or postpartum status and keep individuals automatically retained. For current and former foster youth who are exempt from the requirements, their statuses do not need to be reverified until the enrollee turns age 26.

Eligible Community Engagement Qualifications: The guidance also confirmed eligible qualifications for meeting the community engagement requirements. The new rules confirmed that only students enrolled in an educational program part or full time meet the community engagement component; however, for those enrolled less than part time, credit hours can count towards the required 80 hours in addition to other eligible activities. Those with a monthly MAGI-based household income of at least $580 (e.g., the federal minimum wage multiplied by 80 hours) will also meet requirements; for seasonal workers, the average monthly MAGI-based household income for the months in between eligibility checks must be at least $580.

Compliance: The new federal rules also give states guidance for assessing compliance. States are permitted to use self-attestation for the first year of implementation, but they must require documentation “whenever reasonably available” beginning in 2028. However, New Hampshire lawmakers have chosen not to allow self-attestation at all, which goes beyond the federal law and could create more administrative burden for both the State and individuals renewing their coverage. Under the guidance, documentation must be accepted through all available channels, including through mail, in-person, and online. The guidance also specified that there cannot be a lookback period at application or renewal, as well as more frequent compliance checks, for excluded individuals with an exemption.

Federal guidance directs states to use existing data whenever possible to verify that enrollees meet work requirements or qualify for an exemption, rather than requiring people to submit additional paperwork. If information is not made available through ex parte, states are then permitted to request additional information from enrollees to assess whether or not they comply with the requirements. States are required to use payroll and income data; SNAP, Temporary Assistance for Needy Families (TANF), and other assistance data; and other federal sources, including the Federal Data Services Hub and the federal Emmy system, which is a new consent-based verification model that requires users to log into their personal payroll, bank, or other accounts and consent to share their income information with the Medicaid agency.[15]

Most Implementation Policy Decisions Left Up to States

While states are required to comply with the changes made to Medicaid under the new federal law, states are given flexibility to make certain implementation decisions, which could ultimately impact how many Granite Staters are able to retain their Medicaid coverage over time. According to early estimates from the Urban Institute, anywhere from 14,000 to 29,000 enrollees could lose coverage by 2028 under the new work requirements, depending on the policy implementation details left to the states.[16] Based on decisions New Hampshire has made so far, the State appears more likely to fall toward the middle-to-upper end of that range, which would lead to estimated coverage losses resulting in 23,000 to 29,000 fewer enrolled people.

Several Key Decisions Made During the 2026 Legislative Session

Some implementation decisions were already made during the 2026 legislative session, with New Hampshire imposing more stringent requirements than those required under H.R. 1.[17] Under the new law, Granite Advantage adults must provide documentary evidence of meeting the work requirements, rather than self-attesting to meeting them, which is permitted for the first year of implementation under the federal law. Verification and documentary proof will also be required at least quarterly, which is more frequent than the once every six months required by federal law. Based on early information available as of March 2026, only one other state, Indiana, had planned to conduct quarterly compliance checks.[18] Despite more frequent compliance checks, New Hampshire will require new enrollees to meet requirements for only one month prior to enrollment, which is the minimum amount of time required under federal law. During a June 2026 meeting among the New Hampshire Legislature’s Health and Human Services Oversight Committee (HHSOC), lawmakers voted to allow coverage redeterminations every six months, with enrollees required to verify compliance for one month between redeterminations.[19]

The New Hampshire Department of Health and Human Services (DHHS) is permitted to use ex parte records to verify exemptions and keep people automatically enrolled in coverage, although enrollees will be required to submit documentary proof of an exemption if they are not automatically retained. The new State law also defines the parameters of the medical frailty exemption, requiring a statement from a medical provider (including “a physician, physician associate, nurse, nurse practitioner, designated representative of the physician’s office, a licensed or certified psychologist, or a social worker”) certifying that a condition impairs an individual’s ability to perform activities of daily living (including “eating, dressing, bathing, grooming, getting in and out of bed and chairs, walking, going outdoors, using the toilet, or is in treatment for a chronic substance use disorder”).[20] The DHHS is also not permitted to add new exemption categories or expand the definitions of existing exemptions without permission from the New Hampshire Legislature’s HHSOC. During a June meeting, the HHSOC approved allowing self-attestation of medical frailty for the first year of implementation only.[21]

Enrollees who fail to comply with the requirements will be notified and given a 30-day grace period to provide proof of compliance or an exemption, after which the DHHS may disenroll individuals.

The DHHS is obligated to submit all required documentation and a detailed implementation plan to the U.S. Centers for Medicare and Medicaid Services (CMS) by December 1, 2026, and to the New Hampshire Joint Legislative Fiscal Committee before then. To track progress, the DHHS is required to provide the Legislature with regular reports on the implementation of the work requirements.

Outreach Strategy and Other DHHS Efforts

The DHHS has laid out its internal plan for implementing work requirements, which it has formally named Project COMPASS, or Coordinating Medicaid and Public Assistance System Shifts. This initiative aims to prepare residents, staff, and provider partners for the upcoming changes to both Medicaid and SNAP eligibility, and create transparency around requirements and implementation timelines.

The State has reported that outreach efforts for enrollees redetermining their coverage will begin in early January 2027, with initial notifications sent around three months before each enrollee’s coverage renewal date. Notifications will be sent via mail and electronically, and will specify requirements, eligible exemptions, and how to comply. The DHHS also partnered with CMS for an optional outreach campaign, with text and emails sent through July and August to those who had elected to receive electronic communications. The DHHS website also provides a high-level overview of all changes to Medicaid, including the new work requirements.[21]

Several Implementation Decisions Still Ahead

While the State has already made several implementation decisions, some components will still need to be decided within the next few months before work requirements begin in January 2027.

Medical Frailty Requirements: One of the biggest remaining questions is how New Hampshire will determine who qualifies as medically frail and is therefore exempt from the work requirements. It is still unclear how New Hampshire’s existing law will interact with the new federal guidance. The federal guidance calls for states to use specific diagnostic codes and health conditions when determining medical frailty, which will likely require New Hampshire to compile a list of qualifying conditions. Making this list publicly available could help enrollees understand whether they may qualify for an exemption and what steps they need to take to maintain coverage.

In a recent meeting between the CMS and the states, the federal government outlined a three-tiered system that states could use to determine medical frailty exemptions.[22] These tiers include:

• Tier 1: conditions that significantly impair an individual’s ability to participate in the work requirement, based on code data in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)[23]
• Tier 2: conditions that may indicate medical frailty, but more information is needed to determine significant impairment, including assessing severity or functional status (e.g., elevated acute care utilization, high-risk polypharmacy, use of certain medical equipment)
• Tier 3: insufficient or no available data to assess medical frailty, requiring a manual review process and documentation

The CMS also advised using administrative data to identify enrollees who are medically frail, including fee-for-service (FFS) claims data, the all-payer claims database, short-term disability and workers’ compensation claims, electronic health records, and managed care encounters.

The tier system and the use of administrative data were categorized as optional; however, states may choose to use different approaches. Despite how medical frailty exemptions will be determined in New Hampshire, the recent federal guidance goes beyond what was originally included in H.R. 1 and will likely require more administrative work than originally planned. States may need to update their eligibility systems to meet the new diagnostic requirements, add new staff to process additional paperwork, or train current staff on strategies for identifying individuals who are medically frail, all of which would likely require additional time and resources.

Automatic Renewal and Data Matching Tools: The DHHS has reported that they are currently onboarding and piloting the federal government’s new Emmy ex parte data tool. Under the new federal guidance, the State will also be required to use payroll and social assistance data, although it is unclear what other, if any, data matching sources will be used to help keep people automatically enrolled in coverage. In early implementation surveys conducted in March 2026, New Hampshire reported planning to use the National Student Clearinghouse and Veterans Administration benefit summary letters to help identify and automatically retain enrollees.[24]

Optional Hardship Exemptions: The DHHS has requested to allow all four optional hardship exemptions that were outlined in H.R. 1, pending legislative approval. These include individuals receiving inpatient or institutional care; those traveling outside of their community for an extended period for medical care for themselves or a dependent because care is not available locally; those living in a county with a federal emergency or disaster declaration; and those living in a county or locality with a high unemployment rate (over 8% or greater than 1.5 times the national rate).

While the DHHS has elected to include these exemptions, several details remain at the State’s discretion. For example, the State is required to establish procedures for determining inpatient and institutional care and for specifying which services are included. In addition, the State will be required to specify how they measure unemployment statistics. For those seeking a hardship exemption due to travel for health care services, the State must also define what classifies as “community,” “extended period,” or “not available locally.” In a rural state like New Hampshire, where many Granite Staters are traveling far distances for health care services, this exemption may be particularly important for keeping more people enrolled. Rural communities are more likely to face challenges with broadband internet and postal service access, higher job loss and slower employment growth, and decreased access to health care services, all of which are likely to contribute to higher rates of disenrollment.[25]

Enrollees with an inpatient care or health care travel hardship will also be required to request exemptions for those hardships directly through the DHHS, which could make education and community outreach vital for helping ensure enrollees are aware of their options.

Community Partnerships: Coordination between the State and community providers, including MCOs, will be vital for minimizing disenrollments. The new federal rules provided guidance on which duties MCOs may be responsible for or may assist the State with, depending on the arrangement. These included assisting with outreach notices and educating enrollees, referring enrollees to services to help meet work requirements (e.g., work or training programs), and sharing certain administrative costs associated with outreach, which would be eligible for federal Medicaid match dollars.[26] While MCOs cannot determine compliance or eligibility, these shared responsibilities can help fill gaps where the DHHS may need additional administrative capacity.

Lessons Learned from Other States

Forty-three states and the District of Columbia are required to begin Medicaid work requirements by January 2027, although three states have elected to begin earlier.

Nebraska was the first state to implement work requirements, with enforcement beginning in May 2026 and disenrollments beginning three months later in August. Early enrollment data through August show that most enrollees meet the requirements, with approximately 34% complying with requirements and 57% qualifying for an exemption. However, around 533 enrollees, or 7% of individuals up for determination, have lost coverage; among those who lost their coverage, about 92% did not respond to verification compliance requests. In addition, approximately 14% of individuals applying for Medicaid coverage were denied; around 84% did not respond to requests for additional information.[27] Disenrollments are likely to continue, and an estimated 28,000 to 41,000 adults (around 40-59% of Nebraska’s Medicaid Expansion population) are projected to lose coverage by 2028, according to estimates from the Urban Institute.[28]

While information about initial disenrollments is still being reported, outreach and implementation challenges in Nebraska can provide guidance for other states beginning implementation soon. In December 2025, five months before implementation began, Nebraska’s Department of Health and Human Services sent letters to every Medicaid Expansion adult subject to the new requirements. Follow-up notices were also sent via text message and email to enrollees with an electronic notice preference, although only around half of households reported receiving a text message, and fewer than 15% received an email.[29] Nebraska has also seen an increase in call center inquiries and wait times since implementation began in May, with approximately 36,000 additional calls each month and an average wait time of nearly 13 minutes.[30] Nebraska is one of the few states, including New Hampshire, that do not allow self-attestation to prove employment, although documentation is not required for most enrollees with an exemption (e.g., medical records for those with a health condition or disability).[31]

Montana also began enforcement early in July and plans to begin disenrollments in October.[32] While there is limited public information available on implementation thus far, Montana has experienced record-low Medicaid enrollment in recent years. Following the 2023 federal termination of the pandemic-related continuous enrollment provision, commonly referred to as the “unwind,” enrollment in Montana’s Medicaid program declined by an estimated 57%, the largest drop in the country.[33] Montana has also reported several ongoing administrative challenges, including workforce shortages, call center issues, and long application turnaround and redetermination timelines, which have likely imposed additional constraints during work requirement implementation.[34]

Arkansas began a soft launch of requirements in July, although disenrollments will not begin until next year.[35] Arkansas is the only state to have implemented work requirements before H.R. 1 was passed into law. First implemented in June 2018, more than 18,000 enrollees lost coverage by December, with a federal court ruling halting the requirements in April 2019.[36] Similar to New Hampshire’s 2019 experience with state-level Medicaid work requirements, the majority of coverage losses in Arkansas were due to procedural issues and a lack of knowledge of the work requirements among enrollees, rather than a failure to engage with the work requirements.[37] Research has shown that Arkansas’ work requirements led to an increase in the uninsured rate, as well as no associated impact on employment.[38]

Increased Eligibility Staff Capacity: Early implementation surveys conducted in January through March 2026 reported that fourteen states planned to increase eligibility staff capacity, with nine planning to hire new eligibility workers and seven planning to hire contractors. While New Hampshire officials did not indicate whether they would increase eligibility staff capacity at the time of the survey, a current widespread workforce shortage and a hiring freeze across the DHHS will likely create challenges meeting increased administrative needs.

Allowed Self-Attestation for Medically Frail Enrollees: While some states are requiring documentation for work compliance, many are planning to allow self-attestation for medically frail individuals. Using the same survey data from January through March, thirty states had reported planning to allow self-attestation for those seeking a medically frail exemption. By allowing enrollees to self-attest to having a disabling condition, they will not be required to undergo the extensive process of requesting medical records or provider letters.[39]

Expanded Enrollee Outreach: While states are required to utilize certain standard outreach efforts, many are preparing for more extensive initiatives. New Mexico is planning a paid media campaign, including radio and newspaper ads, billboards, digital displays, and a video commercial, as well as a statewide roadshow to deliver in-person presentations. Rhode Island also plans to use paid ads and social media to help reach more people, while the District of Columbia will run ads on public transportation and share information at health fairs and other city events.

Established Community Education: In addition to outreach for enrollees, many states have also elected to conduct outreach with health providers. Illinois has developed a webinar series with several modules where participants can learn more about changes to work requirements. Montana has led partner briefing webinars providing information on the changes and how providers can assist enrollees. Colorado has developed a separate webpage for community partners and other stakeholders, providing information on changes, including webinars and FAQ sections. Maryland is going a step further by conducting outreach to employers of Medicaid enrollees, who can help provide a trusted information-sharing network for their employees.[40]

Looking Ahead: Estimated Coverage Losses, Funding Reductions, and Overall Impacts to the System

An estimated 75% of adults enrolled in Medicaid in New Hampshire are working, including around 45% who are employed full-time and 30% part-time.[41] Despite this labor force engagement, many Granite Advantage adults are expected to lose coverage due to procedural reasons, including increased documentation and administrative burden, as well as a lack of knowledge of requirements.

According to early estimates from the Urban Institute, between 14,000 and 29,000 fewer adults are expected to be enrolled in the Granite Advantage program due to the work requirements and more frequent redeterminations.[42] These numbers are based on three mitigation scenarios that categorize implementation policy decisions:

• High mitigation, low disenrollment (14,000 individuals disenrolled): use of extensive automatic data-matching (including integrated SNAP-Medicaid eligibility systems); use of minimum allowable work effort (one month before application and between redeterminations); broader exemption definitions (including with medical frailty); use of self-attestation
• Medium mitigation, medium disenrollment (23,000 individuals disenrolled): falls somewhere between the two high and low scenarios
• Low mitigation, high disenrollment (29,000 individuals disenrolled): less use of extensive automatic data-matching; require documentation and limited use of self-attestation; greater use of high work effort (three months before application and between redeterminations); use of narrower exemption definitions

Based on the implementation decisions made in New Hampshire thus far, it is likely that between 23,000 and 29,000 fewer enrollees (around 48-60% of the August 2026 Granite Advantage population) will be enrolled. More frequent verifications, stricter exemption definitions, and not allowing self-attestation push New Hampshire towards the low mitigation scenario, while a one-month lookback period at application could help lessen disenrollments relative to the lowest mitigation efforts. The adoption and successful rollout of extensive automatic data-matching sources will likely have a large influence on whether New Hampshire ultimately falls closer to the medium or low mitigation scenario.

Using similar methodology and mitigation scenarios, a more recent Urban Institute report shows that approximately 2,000 to 6,000 young adults age 19-24 could lose coverage in New Hampshire as a result of the work requirements and more frequent redeterminations. Based on the decisions made by State lawmakers thus far, it is likely that closer to 4,000 to 6,000 young adults will lose coverage.[43]

While changes to Medicaid will directly impact enrollees, changes to financing mechanisms are expected to reduce available funding for health coverage and services. Reductions in provider taxes will lower the State’s Medicaid Enhancement Tax rate over time, likely forgoing more than $2 billion in State and federal funding, and threatening the stability of funding streams for the state’s Medicaid system.[44] Changes to state-directed payments, which currently fund hospital uncompensated care, community mental health, and other crucial health services, could limit the federal funding available to New Hampshire.[45]

States will also likely lose significant federal funding due to changes to Medicaid enrollment, including the new work requirements. Based on SFY 2026 enrollment and expenditure data, New Hampshire spent an average of $12,485 in federal dollars per Granite Advantage enrollee. If 23,000 enrollees were to lose coverage under the new work requirements, the state would have lost an estimated $362.1 million in federal funding flowing to New Hampshire health care providers based on figures from SFY 2026 alone.[46]

The loss of significant federal funding and increase in uncompensated care are both likely to impact prices elsewhere in the health care system. National projections on the impact of an earlier version of the federal reconciliation bill, which would have likely led to larger disenrollments than the final version, estimated a $198 billion increase in uncompensated care for uninsured individuals by 2034, with hospital services accounting for 31% of this increase, while 12% were in physician services, 20% in prescription drugs, and 37% in other services.[47] While the version of the federal reconciliation bill ultimately passed is unlikely to result in losses of this magnitude, significant coverage losses are still projected and could have broader effects on costs.

When more people become uninsured, providers must either absorb the costs of uncompensated care or seek other revenue sources to maintain their operations. One common potential mechanism is cost shifting, in which providers negotiate higher payment rates with private insurers to partially offset losses from uncompensated care. As a result, higher payment rates can increase insurers’ health care spending and contribute to higher private health insurance premiums over time.

Medicaid Expansion has played a significant role in reducing the uninsured rate, while also bringing additional public funding into the health care system. A national study measuring the initial impacts of Medicaid Expansion found that it reduced uncompensated care, particularly for high-cost hospital services. Between 2013 and 2015, every $1 a hospital spent on uncompensated care in an expansion state declined by 41 cents, resulting in an estimated $6.2 billion reduction in uncompensated care across states that had expanded Medicaid by 2015.[48] In New Hampshire, the uninsured rate declined by more than half following the passage of Medicaid Expansion, falling from 10.7% in 2013 to 5.7% by 2017.[49]

Conclusion

New Hampshire is entering a significant period of change for its Medicaid program over the coming decade, including changes to eligibility, new enrollment processes, and the implementation of new work requirements. The State has already adopted several policies that go beyond the minimum federal requirements. However, important decisions remain regarding medical frailty and hardship exemptions, data matching and automatic renewal processes, and coordination with managed care organizations and community partners. Those choices could significantly affect how many eligible Granite Staters can maintain coverage when the new requirements take effect in 2027.

The impacts of these changes, however, will extend beyond the Granite Staters who may lose coverage. Broader changes to Medicaid financing are also likely to have large impacts on health care services over time. Reductions to provider taxes and state-directed payments, federal funding losses associated with Medicaid disenrollments, and increases in uncompensated care are likely to create significant funding pressures for New Hampshire. As the State enters its next budget cycle, policymakers will face important decisions around how to address these pressures and ensure adequate funding for health care services that support the well-being of all Granite Staters.

Updates to this Issue Brief were made on October 21 and 29, 2026 to reflect new information.

Endnotes

[1] See the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2026 Poverty Guidelines: 48 Contiguous States.

[2] See KFF’s May 2025 Issue Brief, Understanding the Intersection of Medicaid and Work: An Update.

[3] For population estimates, see the U.S. Census Bureau, Population Estimates Program, City and Town Population Totals: 2020-2025. For prior Medicaid municipal enrollment analyses, see NHFPI’s July 2025 blog, One in Eight Granite Staters Enrolled in Medicaid in 2024, One in Thirteen Adults Enrolled in Medicaid Expansion and September 2024 interactive, One in Seven Granite Staters Were Enrolled in Medicaid in 2023, with Large Variations Between Municipalities. All Medicaid enrollment data used in this Issue Brief was provided by the New Hampshire Department of Health and Human Services. The data represents average member years for calendar year 2025. Member attributes were selected from the latest eligibility month during the measurement period, and towns with less than 5 enrollees were suppressed from the final data.

[4] For more information on Medicaid eligibility for children in New Hampshire, see the NH Department of Health and Human Services’ webpage, NH Medicaid (Medical Assistance) Eligibility for Children.

[5] Note that data may be incomplete, as Medicaid participants are not required to disclose their race or ethnicity at enrollment. Numbers only include enrollees choosing to self-identify.

[6] See the NH Secretary of State, 2022-2032 State Senate Districts.

[7] For enrollment data, see the NH Department of Health and Human Services’ September 2026 caseload report, New Hampshire Medicaid Enrollment Demographic Trends and Geography.

[8] For State Budget language, see Chapter 141, Laws of 2025 (House Bill 2). For more information on the State Budget, see NHFPI’s July 2025 Report, The State Budget for Fiscal Years 2026 and 2027.

[9] For more information on the Medicaid unwind, see NHFPI’s April 2024 blog, Granite Staters Continue to be Impacted by End of Continuous Medicaid Enrollment One Year Later.

[10] For more information on waivers, see the U.S. Centers for Medicare and Medicaid Services, COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals.

[11] See the U.S. Centers for Medicare and Medicaid Services, State Medicaid and CHIP Eligibility Processing Data. 2025 quarter 1 data were final counts, and 2026 quarter 1 data are preliminary counts. All numbers represent averages for the three months.

[12] To read the full 2025 federal reconciliation law, see H.R. 1 – One Big Beautiful Bill Act on the Congress.gov website. For a detailed analysis, including more information about the changes to Medicaid, see NHFPI’s August 2025 Issue Brief, New Federal Reconciliation Law Reduces Taxes, Health Access, and Food Assistance Supports for Granite Staters.

[13] See State Health and Value Strategies’ June 2026 analysis, CMS Releases Interim Final Rule on Medicaid Work Reporting Requirements.

[14] To read the full interim final rule on work requirements, see Community Engagement Requirement for Certain Individuals on the Federal Register website. See also the U.S. Centers for Medicare and Medicaid Services (CMS)’s June 2026 factsheet, Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule with Comment Period (CMS-2454-IFC). For more analyses of the rule, see several national resources that were referenced when writing this Issue Brief, including the Center on Budget and Policy Priorities and Georgetown University’s Center for Children and Families’ June 2026 webinar recording; State Health and Value Strategies’ June 2026 webinar recording and additional analysis; National Organization for Rare Disorders’ June 2026 Policy Explainer; and Families USA’s June 2026 factsheet.

[15] For more information on the Emmy system, see the Center on Budget and Policy Priorities’ April 2026 blog, Understanding CMS’s “Emmy” Medicaid Work Requirement Tools.

[16] For more information on estimated coverage losses, see the Urban Institute’s March 2026 Report, Projected Reductions in Medicaid Expansion Enrollment Under OBBBA’s Work Requirements and Six-Month Redeterminations. For monthly Medicaid caseload data, see the NH Department of Health and Human Services, Data Reports, Medicaid Enrollment Data.

[17] See Chapter 18, New Hampshire Laws of 2026. For more analysis on the 2026 legislative session, see NHFPI’s June 2026 blog, New Laws Impacting Health, Child Care, Education, Housing, and Fiscal Policy Pending at End of Legislative Session.

[18] See KFF’s April 2026 analysis, An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements, Appendix Table 1.

[19] See the NH Department of Health and Human Services’ presentation to the NH Health and Human Services Oversight Committee, Medicaid Community Engagement & Work Requirements; and Meeting Minutes, June 26, 2026.

[20] Chapter 18, New Hampshire Laws of 2026.

[21] See the NH Department of Health and Human Services’ presentation to the NH Health and Human Services Oversight Committee, Medicaid Community Engagement & Work Requirements; and Meeting Minutes, June 26, 2026.

[22] See the NH Department of Health and Human Services’ presentation, Project COMPASS: Coordinating Medicaid & Public Assistance System Shifts; webpage, Stay Covered New Hampshire; and press release, NH DHHS Partners with US CMS on Outreach and Education Campaign to Prepare Medicaid Granite Advantage Members for New Federal Work Requirements.

[23] For more information on the three-tiered system, see the U.S. Centers for Medicare and Medicaid Services’ September 2026 presentation, Implementing Medical Frailty Under Community Engagement (Section 71119 of WFTC Legislation).

[24] See the U.S. Centers for Disease Control and Prevention, ICD-10-CM.

[25] See KFF’s April 2026 analysis, An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements, Appendix Table 8.

[26] See Georgetown University’s Center for Children and Families’ September 2026 Report, Rural Communities at Greater Risk of Harmful Impacts from New Medicaid Work Reporting Requirements.

[27] See the Center on Budget and Policy Priorities and Georgetown University’s Center for Children and Families’ June 2026 presentation, slide 30.

[28] See the KFF’s September 2026 analysis, Early Medicaid Work Requirement Insights From Nebraska.

[29] For more information on estimated coverage losses, see the Urban Institute’s March 2026 Report, Projected Reductions in Medicaid Expansion Enrollment Under OBBBA’s Work Requirements and Six-Month Redeterminations.

[30] See Families USA’s April 2026 blog, Nebraska’s Rushed Implementation of Medicaid Work Reporting Requirements Puts Residents’ Health at Risk.

[31] See the NE Department of Health and Human Services’ ACCESSNebraska Performance Metrics: July 2026.

[32] For more information on Nebraska’s work requirement implementation progress, see the NE Department of Health and Human Services’ webpage, Work Requirements; KFF Health News’ April 2026 article, Trump’s Medicaid Work Mandate Debuting in Nebraska to Much Dismay, Nebraska’s Plan; and KFF’s January 2026 blog, A Closer Look at Nebraska, the First State Planning to Implement a Medicaid Work Requirement.

[33] For more information on Montana’s work requirement implementation progress, see the MT Department of Public Health and Human Services’ webpage, Changes to Medicaid and KFF Health News’ May 2026 article, Montana Hurries to Adopt Trump’s Medicaid Work Rules Amid Budget Woes.

[34] See KFF, Medicaid/CHIP Monthly Enrollment Tracker, Unwinding Data – Achieved.

[35] For more information on administrative challenges, see the Montana Budget and Policy Center’s April 2026 Report, Montana’s Administration of Medicaid and Poor Customer Service Costs People and the State.

[36] For more information on Arkansas’ work requirement implementation progress, see the AR Department of Human Services’ webpage, ARHOME Community Engagement and Work Requirement.

[37] For more information on Arkansas’ prior experience with work requirements, see the Urban Institute’s October 2019 Report, Lessons from Launching Medicaid Work Requirements in Arkansas.

[38] For more information on New Hampshire’s prior experience with work requirements, see NHFPI’s May 2019 Issue Brief, Medicaid Work Requirements and Coverage Losses.

[39] See the Urban Institute’s April 2025 article, New Evidence Confirms Arkansas’s Medicaid Work Requirement Did Not Boost Employment.

[40] For more information on the survey, see KFF’s April 2026 analysis, An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements.

[41] For more information on outreach strategies in other states, see KFF’s July 2026 analysis, Medicaid Work Requirements: Federal Outreach Requirements and State Plans and Georgetown University’s Center for Children and Families’ May 2026 blog, What Do We Know So Far About State Materials & Consumer Outreach on Medicaid Work Reporting Requirements?

[42] See KFF’s May 2025 factsheet, Medicaid in New Hampshire.

[43] For more information on estimated coverage losses and mitigation scenarios, see the Urban Institute’s March 2026 Report, Projected Reductions in Medicaid Expansion Enrollment Under OBBBA’s Work Requirements and Six-Month Redeterminations.

[44] See the Urban Institute’s September 2026 Brief, Up to 2.3 Million Young Adults Ages 19 to 24 Could Lose Medicaid Under OBBBA’s Work Requirements and More-Frequent Redeterminations.

[45] For more information on reductions to provider taxes, see NHFPI’s February 2026 Report, Hospital Provider Taxes and Support for Medicaid Financing in New Hampshire.

[46] For more information on state-directed payments, see KFF’s June 2026 analysis, Spending on Medicaid State Directed Payments Before New Limits Take Effect and The Commonwealth Fund’s July 2025 blog, How Medicaid State-Directed Payments Support Critical Health Care Providers.

[47] Enrollment numbers are calculated using the average month-end caseload count for each month of State Fiscal Year 2026 (July 1, 2025 to June 30, 2026). For caseload numbers, see the NH Department of Health and Human Services’ February report and September report. For Granite Advantage spends, see the NH Joint Legislative Fiscal Committee’s September Meeting Agenda Item FIS 26-171.

[48] For early uncompensated care projections, see the Urban Institute’s May 2025 Brief, Reconciliation Bill and End of Enhanced Subsidies Would Cut Health Care Provider Revenue and Spike Uncompensated Care. Estimates are based on the U.S. House of Representatives’ earlier version of the federal reconciliation bill, which would have ultimately ended Medicaid Expansion. Uncompensated care losses are still expected to be significant, although the final bill version passed into law will likely have a lesser impact compared to earlier versions.

[49] See The Commonwealth Fund’s May 2017 Issue Brief, The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal.

[50] See the U.S. Census Bureau, American Community Survey, Table S2701, 1-year estimates. For more information about the impact of Medicaid Expansion in New Hampshire, see NHFPI’s January 2023 Issue Brief, The Effects of Medicaid Expansion in New Hampshire.