New Hampshire Medicaid Expansion: Eligibility, Costs, and Work Rules

New Hampshire’s Medicaid expansion, officially the Granite Advantage Health Care Program, covers adults aged 19 through 64 with household income at or below 133% of the federal poverty level. About 50,800 adults are enrolled, roughly a third of the state’s total Medicaid population.¹ The program is in the middle of major changes: monthly premiums arrive in July 2026, higher prescription copays already took effect in January 2026, and a federal work requirement must be in place by January 2027.

Who Qualifies

To enroll in Granite Advantage, you must be between 19 and 64 years old, have household income at or below 133% of the federal poverty level, be a U.S. citizen or qualified immigrant, and live in New Hampshire with the intent to remain.²

You are not eligible for the expansion program if you are pregnant, enrolled in Medicare, or qualify for disability-based Medicaid. Those groups are covered under other Medicaid categories with their own income rules and, in some cases, resource tests. Children, parents and caretaker relatives, elderly residents, and people with disabilities have separate pathways into coverage.²

An important shift is coming for lawfully present immigrants. Effective October 2026, the federal One Big Beautiful Bill Act makes many lawfully present immigrants, including refugees and asylees, ineligible for Medicaid regardless of how long they have lived in the country.³

What It Covers and How You Get Care

Granite Advantage benefits are delivered through three managed care organizations: AmeriHealth Caritas New Hampshire, NH Healthy Families, and WellSense Health Plan. All three cover the same core Medicaid services, but their provider networks, prior authorization rules, and supplemental benefits differ. If you don’t pick a plan, you are auto-assigned to one. You can switch during your first 90 days of enrollment, during open enrollment, or for cause.⁴

A few services stay outside managed care and are billed under traditional fee-for-service Medicaid: children’s dental care, nursing home care, and home and community-based care waiver services.⁴

Medicaid is also the single largest payer for substance use disorder treatment in New Hampshire. Of the state’s $57.8 million in Medicaid spending on substance use disorder prevention, treatment, and recovery in 2024, 79% flowed through the expansion program.⁵ A separate Section 1115 waiver covering substance use disorder, serious mental illness, and community reentry services runs through June 30, 2029.⁶

What You’ll Pay Starting in 2026

For most of its history, Granite Advantage carried no monthly premium. That changes July 1, 2026. Under the state budget signed by Governor Kelly Ayotte in June 2025, enrollees with household income at or above 100% of the federal poverty level (about $15,960 for a single person) must pay a monthly premium. The amount ranges from $60 for an individual to $100 for a family of four or more. The Department of Health and Human Services projects the premium system will generate up to $23 million in revenue for fiscal year 2027.⁷

Prescription copays went up in January 2026. Copayments on preferred drugs rose from $1 to $2 per prescription to $4 per prescription. There is an exemption if your out-of-pocket costs exceed 5% of household income.⁸

The New Work Requirement

A work and community engagement requirement is coming. Senate Bill 134, signed in 2026, aligns New Hampshire with the federal mandate created by the One Big Beautiful Bill Act. Non-exempt expansion enrollees aged 19 to 64 must work or engage in qualifying activities for at least 80 hours per month.⁹ The federal law requires states to have the requirement in place by January 2027.³

Documentation matters. SB 134 requires documentary verification rather than self-reporting, with verification at least quarterly. Exemptions are limited to people certified as medically frail by a provider, and DHHS is barred from adding new exemption categories without legislative approval. Implementation reporting begins in January 2027.⁹

New Hampshire has been here before. The state received federal approval for a 25-hour-per-week community engagement requirement in 2018 and began implementation in 2019. Within months, the state suspended it after determining that nearly 17,000 adults would lose coverage, and a federal judge later struck it down. The dynamic is different now because the federal law makes work requirements national rather than a state-by-state waiver fight.¹⁰

An estimated 20,000 New Hampshire residents are expected to lose Medicaid coverage because of the work requirement alone.³

Shorter Renewal Cycle and Less Retroactive Coverage

Two other changes affect how you keep your coverage and how far back benefits reach.

Eligibility redeterminations have moved from once a year to every six months. If you miss a renewal or your paperwork isn’t current, you are at risk of losing coverage twice as often as before.¹¹

Retroactive coverage, the window during which Medicaid will pay for care you received before your application was approved, has also been shortened. For expansion enrollees it drops from 90 days to 30 days. For other Medicaid recipients it drops from 90 days to 60 days.¹¹ Both changes mirror provisions in the federal One Big Beautiful Bill Act.

Federal Cuts and What They Mean for New Hampshire

The One Big Beautiful Bill Act, Public Law 119-21, was signed on July 4, 2025, and makes sweeping changes to federal Medicaid policy. Beyond the work requirement, six-month redeterminations, and retroactive coverage limits, the law caps provider taxes. Starting October 2027, the maximum provider tax rate is capped at 5.5%, declining by half a percentage point per year to 3.5% by October 2031.³

Federal Medicaid spending in New Hampshire is projected to fall by approximately $2.3 billion over the next decade.³ A KFF analysis projects that between 17,000 and 29,000 state residents could lose health coverage by 2034 as a result of the law’s combined provisions. Analysts expect 2027 and 2028 to be particularly difficult years, when changes to provider payment rules and non-federal financing take effect at the same time.¹²

For context on how much federal money is at stake, Granite Advantage brought roughly $502 million in federal dollars into New Hampshire in its most recent full fiscal year, with the federal government covering 90% of expansion costs compared with 50% for traditional Medicaid.¹³¹⁴ State law (RSA 126-AA) prohibits using general fund dollars to cover the state’s share, relying instead on insurance premium tax revenue, voluntary contributions from insurers and hospitals, and Liquor Commission revenue as a backstop.

The Trigger Law That Could End the Program

Buried in the 2018 reauthorization is a provision that could end Granite Advantage entirely. If the federal matching rate for expansion enrollees ever drops below 90%, the program is automatically repealed. Repeal takes effect 180 days after the trigger activates, and enrollees must be notified within 10 days.¹⁵

As of mid-2026, the federal expansion match remains at 90% and the trigger has not activated.⁸ If the match were dropped to 50%, the state would face an estimated $249.1 million in additional annual costs, and the general-fund prohibition in RSA 126-AA would make covering that gap very difficult even if lawmakers repealed the trigger itself.¹⁵ Senate Democrats tried to remove the trigger during the 2025 session, but Senate Republicans blocked the effort as not germane.¹⁶

What’s Being Debated

The new premiums are already drawing a legislative response. Senate Bill 484, the “Lowering the Cost of Health Care Act of 2026,” would repeal the premium requirements for Granite Advantage and CHIP enrollees, cap cost-sharing at $5 per service beginning October 2028, and appropriate $16 million for fiscal year 2027 to offset lost premium revenue. Senator Cindy Rosenwald is leading the bill, which sits with the Senate Finance Committee.¹⁷

Governor Ayotte has defended the premiums and copay increases as necessary for state budget health. Democratic gubernatorial candidate Cinde Warmington has called the premiums an “income tax on the poor” and has said reversing them would be a top priority if she is elected.¹⁸ With the November 2026 gubernatorial election ahead and the premium system scheduled to launch the following summer, how the program looks in practice is still being written.

1
NH DHHS. Medicaid Enrollment Report
2
NH DHHS. NH Medicaid Medical Assistance Eligibility
3
NH Fiscal Policy Institute. New Federal Reconciliation Law Reduces Taxes, Health Access, and Food Assistance Supports
4
NH DHHS. Medicaid Care Management
5
NH Fiscal Policy Institute. Substance Use Disorder Funding in New Hampshire
6
CMS. NH SUD Treatment Recovery Access Extension Approval
7
New Hampshire Bulletin. Medicaid Premium System Could Bring New Hampshire Up to $23 Million in Revenue
8
New Hampshire Bulletin. Medicaid Cuts Have Dominated NH Headlines This Year
9
NH Fiscal Policy Institute. 2026 Legislative Wrap-Up
10
NH Fiscal Policy Institute. Up to 19,000 Granite Staters Could Lose Medicaid Coverage Under Potential Federal Work Requirements
11
New Hampshire Bulletin. Medicaid Is Changing, Granite Staters Deserve Answers
12
Carsey School of Public Policy, UNH. What the One Big Beautiful Bill Act Select Provisions Mean
13
NH Fiscal Policy Institute. The Effects of Medicaid Expansion in New Hampshire
14
MACPAC. FMAP and Enhanced FMAP by State
15
NH Fiscal Policy Institute. Potential Federal Medicaid Policy Changes Could Shift Substantial Costs to States
16
NHPR. New Hampshire Medicaid Funding Budget Cuts
17
New Hampshire General Court. SB 484-FN
18
Valley News. Ayotte, Warmington Medicaid Debate