Relative to clinical eligibility criteria for nursing facility and home and community based care.
Summary
SB 125 revises New Hampshire’s Medicaid clinical eligibility rules for nursing facility services and home- and community-based waiver care. The bill updates RSA 151-E:3 to expand the activities of daily living used in eligibility determinations by adding mobility, and it keeps the basic structure that a person must be both clinically eligible and financially eligible for long-term care coverage. It also corrects a federal regulatory citation for the term “skilled professional medical personnel” and clarifies that those personnel, or someone with equivalent training designated by the department, are responsible for making the clinical eligibility decision using an approved assessment tool.
The bill further requires the Department of Health and Human Services to consider information from an applicant’s primary care physician and other health care providers when the assessment tool does not establish eligibility, and it directs the department to obtain a long-term-care determination from the applicant’s primary care physician or nurse practitioner in those cases. For annual redeterminations, the bill bars denial of eligibility unless the individual’s primary care physician, physician assistant, or nurse practitioner agrees that the person no longer meets the level of care standard. It also includes a provision, subject to federal approval, allowing financial eligibility based on income at or below the nursing facility special income standard or through allowable medical expenses that reduce income to that level.
Impact
SB 125 would amend RSA 151-E:3, the state statute governing Medicaid eligibility for nursing facility care and home- and community-based waiver services. It would change both the clinical assessment process and the redetermination process, expand the list of qualifying functional impairments, and require broader use of medical-provider input in eligibility decisions. The bill also directs DHHS to seek federal approval for a related financial-eligibility rule change within 30 days of enactment. According to the fiscal note, the measure could increase Medicaid expenditures by more than $5 million annually, split between general and federal funds, and could affect the size and administration of the Choices for Independence program and other long-term-care caseloads.
Sentiment
The overall sentiment appears mixed to supportive of expanding access to long-term care, but with significant administrative and fiscal caution from the Department of Health and Human Services. The bill’s structure suggests a policy preference for more individualized, provider-informed eligibility decisions and for making it harder to terminate services at redetermination. At the same time, the fiscal note indicates the department believes the bill could create delays, uncertainty, and possible federal compliance problems, especially if CMS does not approve the proposed changes.
Contention
The main points of contention are the addition of “mobility” to the activities of daily living without a statutory definition, the requirement that primary care providers effectively participate in or agree with eligibility denials, and the possibility that these provisions could slow determinations or conflict with federal Medicaid rules. DHHS warns that the bill could make it harder to deny ineligible applicants, jeopardize the 45-day federal determination timeline, and risk federal financial participation if CMS does not approve the changes. Supporters are not quoted in the provided materials, but the bill’s text indicates an intent to broaden access and give greater weight to treating clinicians’ judgments in long-term-care eligibility decisions.