Independent New Hampshire Journalism · Northfield, NH

Caregivers Are Exempt From Medicaid Work Rules. New Hampshire Won’t Take Their Word for It.

A state law approved March 27, 2026, set aside New Hampshire’s 100-hour Medicaid work rule and adopted the federal exemptions, including one for family caregivers. It also tells the state not to accept a caregiver’s own word as proof.

On March 27, 2026, New Hampshire set aside the 100-hour Medicaid work rule it first wrote into law in 2018. In the same law, it gave the state Department of Health and Human Services a second order: stop taking people at their word.

Chapter 18 of the Laws of 2026 swapped the state’s rule for the federal Medicaid work requirements in the tax and spending law President Trump signed on July 4, 2025. Starting no later than January 1, 2027, Granite Advantage adults who do not qualify for an exemption will need 80 hours a month of work, community service, a work program or half-time school. The state law carried over the federal exemptions, including one for parents and family caregivers of a child 13 or younger or of a disabled person. Then it told the department to verify every exemption through its own records or through documents, and to refuse self-attestation from anyone claiming one.

That is where the risk moved. Washington exempted caregivers, and Concord kept the exemption. But the state closed the simplest way to claim it, and caregiving is a status the Urban Institute says states have limited ability to confirm from data they already hold. Whether a caregiver in Berlin or Claremont keeps coverage in 2027 will turn less on the law than on what the department accepts as proof.

What New Hampshire’s law says

Senate Bill 134 began in 2025 as an order to reapply for a federal waiver for the state’s old 100-hour rule. After Congress acted, Rep. Jim Kofalt, a Wilton Republican, amended it to follow the federal requirements instead. The House adopted his amendment 349-5 on January 8, 2026, and passed the bill 204-150 the same day. The Senate concurred 15-9 on February 5, and the law was approved and took effect March 27.

The new statute, RSA 126-AA:6, defines the work requirements as those in Section 71119 of the federal law and says the federal rules control if the two conflict. A companion section suspends the old state provisions for as long as the federal requirement stands.

Then the Legislature added its own conditions. An applicant must document one month of qualifying activity before enrolling. The department must check compliance with documents at least quarterly between renewals and may not accept self-attestation at any step. It may not add the optional exemptions federal law allows without express approval from the Legislature’s oversight committee on health and human services. A medical-frailty exemption requires a statement from a listed professional, such as a physician, nurse practitioner, psychologist or social worker. Anyone the department cannot verify gets a notice and 30 days, then disenrollment if they cannot show compliance or an exemption.

What Washington requires

The federal rule applies to non-pregnant adults ages 19 to 64 in Medicaid’s expansion group, which New Hampshire runs as Granite Advantage. Each month they must log 80 hours of work, community service, a work program or half-time school, or earn at least 80 times the federal minimum wage, which comes to $580 in 2026. The Centers for Medicare & Medicaid Services issued its implementing rule on June 1, 2026, and states must start no later than January 1, 2027.

The exemptions include pregnant and postpartum women, people who are medically frail, veterans with a total disability rating, former foster youth, and parents, guardians, caretaker relatives or family caregivers of a child 13 or younger or of a disabled individual. States may also offer short-term hardship exceptions.

The rule also tells states how to check. A state must search reliable information it already holds before asking a person for anything. Before January 1, 2028, it may require documents or accept other information; after that, it must require documents whenever they are reasonably available. For caregivers and most other exemptions, two protections hold at every stage. A state must accept information other than documents when none is reasonably available, and it may not deny or end coverage only because someone cannot produce documentation that does not exist.

That federal floor matters because New Hampshire’s statute points to it. RSA 126-AA:6 bars self-attestation, and it also says the federal rules win a conflict. How the department reconciles those two provisions for a caregiver with no paperwork to show is the question its plan has to answer.

Why caregivers carry the most risk

Most exemptions leave a record somewhere. The Urban Institute’s March 25, 2026 report maps each one to data a state might already hold: claims for pregnancy, eligibility files for foster youth, Veterans Affairs records for disabled veterans. For caregivers of a disabled person, it lists no such source. The report says states have limited ability to determine caregiving status automatically. It projects that expansion enrollment nationally would fall 19 to 52 percent among adults who live with a disabled family member, depending on how states carry out the rules, and it names caregivers for disabled family members among the groups at higher risk of losing coverage.

The pool is large. About 281,000 New Hampshire adults, one in four, are family caregivers or were within the past year, according to the AARP and National Alliance for Caregiving spotlight published in October 2025. Across New England, the same survey found that 52 percent of caregivers look after a parent and 19 percent provide at least 40 hours of care a week or constant care. Most of those caregivers are not on Medicaid at all. The ones covered through Granite Advantage sit where the documentation rules land hardest.

AARP New Hampshire State Director Christina FitzPatrick raised the paperwork problem in a July 2025 report published by the Valley News, saying enrollees could lose coverage for missing paperwork deadlines, struggling with the reporting system or lacking the right documents. The same report said Steve Ahnen, president of the New Hampshire Hospital Association, worried that people who lose coverage could lose access to care or take on medical debt they cannot pay. The final federal law does exempt caregivers of disabled individuals. New Hampshire’s ban on self-attestation keeps FitzPatrick’s paperwork worry alive.

Take the example the first version of this article used: a woman in Berlin caring full time for a parent with dementia. Under the statute, she is exempt if her parent counts as a disabled individual. The open question is what the department will accept to show it. The state law names the professionals who can certify medical frailty. It names nothing a family caregiver can hand in.

What the numbers say, and what they don’t

The Urban Institute modeled three ways states might run the rules. For New Hampshire, it projected that average monthly expansion enrollment in 2028 would be about 14,000 lower if the state keeps paperwork to a minimum and applies exemptions broadly, about 23,000 lower under middle-ground choices, and about 29,000 lower if it narrows exemptions and demands more documentation. Those are declines of 27, 44 and 56 percent from where enrollment would otherwise be. They describe lower enrollment in an average month, not a count of people who will be cut off.

New Hampshire’s law does not fit one scenario. Its one-month look-back is the federal minimum, and it lets the department use records it already holds; both choices push toward the smaller estimate. Its ban on self-attestation, its quarterly checks and its gate on optional exemptions push toward the larger one.

The state’s own counts set the scale. As of July 1, 2026, the department said 47,571 Granite Advantage members would face the new rules at their first redetermination in 2027, NHPR reported. Statewide Medicaid enrollment, children included, was 168,652 at the end of May 2026, according to a New Hampshire Fiscal Policy Institute analysis of department data.

New Hampshire has run this test before

The state’s first work requirement began with June 2019 reporting, at 100 hours a month under a federal waiver. According to state data compiled by the New Hampshire Fiscal Policy Institute, 24,766 enrollees had no exemption and had to report. By July, 8,129 had reported meeting the requirement and 16,637 had not. The state paused enforcement before anyone lost coverage, and on July 29, 2019, U.S. District Judge James Boasberg vacated the federal approval in Philbrick v. Azar.

Arkansas did not stop in time. It disenrolled more than 18,000 adults, about one in four of those first subject to its rule, over four months in 2018. Research cited by the Urban Institute later found that more than 95 percent of the people subject to Arkansas’s requirement appeared to be working enough or to qualify for an exemption. By that math, most of the people Arkansas dropped met the rule and lost coverage over reporting.

Premiums are still waiting on Washington

The state budget Gov. Kelly Ayotte signed on June 27, 2025, also set monthly premiums: $60 to $100 for Granite Advantage adults at or above the federal poverty level, and $190 to $270 for families with children in the Children’s Health Insurance Program earning at least 255 percent of it, both depending on family size. State health officials told the Union Leader the premiums would reach about 12,000 Granite Advantage members and about 8,600 CHIP families. They cannot start until federal regulators approve the state’s waiver, and the NH Medicaid Matters coalition lists the Granite Advantage premiums as delayed.

What to watch before January 1, 2027

Chapter 18 sets the calendar. The department must put its implementation plan before the Legislature’s Fiscal Committee for review, then file with the federal government by December 1, 2026, or within 30 days after CMS publishes its application template if that comes sooner. It must also send quarterly status reports to legislative leaders and the governor through December 31, 2026. Under the department’s published guidance, current members face the requirement at their first redetermination in 2027, and people applying in January 2027 must show qualifying activity in December 2026.

Three answers will decide how many caregivers keep coverage. What will the department accept as proof of caregiving when no official record exists? How will it square the state’s self-attestation ban with the federal rule against cutting people off for lacking documents that do not exist? And will it seek, with the oversight committee’s approval, the optional exceptions federal law permits? Once filed, the quarterly reports and the plan are governmental records under RSA 91-A that any member of the public can request.

Congress wrote caregivers into the exemption list, and New Hampshire kept them there. Then the Legislature made the proof harder to give. Lawmakers reviewing the department’s plan on the Fiscal Committee should start with one question: what does a caregiver in Berlin hand the state to keep her coverage?

— Dexter Dow, Granite State Report

Fact check

Editor’s note. This update rests on the enrolled text of Chapter 18, Laws of 2026; the CMS interim final rule and its June 29, 2026 correction; the Urban Institute’s March 25, 2026 report; the AARP and National Alliance for Caregiving New Hampshire spotlight; guidance from the New Hampshire Department of Health and Human Services; and reporting by NHPR, the New Hampshire Bulletin, the Union Leader, the Valley News, the Keene Sentinel and the New Hampshire Fiscal Policy Institute. Remarks attributed to named people come from the published reports cited. This is analysis, not legal advice. Corrections: Granite State Report corrects verified errors promptly and appends a dated note identifying what changed and when. The corrections policy and the corrections register are public, and correction notes are never removed. Write to granitestatereport@gmail.com.