New Hampshire

In New Hampshire

  • In July of 2011 there were a total of 135,092 beneficiaries enrolled in New Hampshire’s Medicaid program, with none of these beneficiaries enrolled in managed care. However, beginning on December 1, 2013, the state transitioned from fee-for-service to a Medicaid care management program under a Section 1932(a) State Plan Amendment. Physical and behavioral health services are provided under the managed care program, while oral health services remain fee-for-service. Children must enroll in a managed care organization (MCO) and will receive physical and behavioral health services under the EPSDT benefit through the MCO. New Hampshire’s Department of Health and Human services has contracted with three MCOs.
As of 2012, 108,727 individuals were eligible for EPSDT through New Hampshire Medicaid. According to CMS data from 2012, New Hampshire achieved an EPSDT screening ratio of 71% and a participation ratio of 62%. 56,296 children received dental services of any kind, with 52,410 receiving preventive dental services.

Last updated May 2014

Medical Necessity
Regulations in New Hampshire define medically necessary as:
“health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:
  1. Clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;
  2. Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;
  3. No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient’s illness, injury, disease, or its symptoms; and
  4. Not experimental, investigative, cosmetic, or duplicative in nature.”
Initiatives to Improve Access
Reporting & Data Collection
Managed care organizations in New Hampshire are required to report on measures sets that include:
  • CHIPRA Child Quality Measures
  • NCQA Medicaid Accreditation and HEDIS/CAHPS Measures
  • CAHPS measures that include for children with chronic conditions
In the first year of operation of the managed care program, the Adolescent Well Care Visits HEDIS measure is a performance incentive measure for managed care organizations.
Behavioral Health
Behavioral health benefits are included in New Hampshire’s new managed care program. Managed care organizations are required to contract with Community Mental Health Centers to deliver behavioral services to Medicaid beneficiaries, including children with a severe emotional disturbance. Clinicians providing community mental health services to Medicaid-enrolled children must be certified in the use of Child and Adolescent Needs and Strengths Assessment.
Support to Providers and Families

New Hampshire provides resources on Medicaid for families of eligible children, and it provides resources on managed care for beneficiaries The state also provides a Medicaid Managed Care Question and Answer for providers.
Care Coordination
Managed care contracts in New Hampshire require that managed care organizations (MCOs) implement comprehensive care management programs that at a minimum contain certain elements, including:
  • Care coordination
  • Support of patient-centered medical homes and health homes
  • Wellness and prevention programs
  • High cost/high risk member management programs

The contracts require that in coordinating care MCOs “ensure that services provided to children are family driven and based on the needs of the child and the family.” Care coordination services for children are required to:
  • Include family involvement
  • Deliver behavioral health services that are anchored in the community
  • Build upon the strengths of the child and family
  • Integrate services among multiple providers and organizations working with the child, and
  • Utilize a wraparound model of care within the context of a family driven model of care.

MCOs are expected to develop relationships with resources in the community, including schools and juvenile justice systems.

Oral Health
The New Hampshire Department of Health and Human Services’ “New Hampshire Smiles” program helps connect Medicaid-enrolled children to dentists. A detailed Dental Provider Manual offers more information on Medicaid-covered services, including under the EPSDT benefit.