New Hampshire’s compact geography creates a distinctive implementation landscape. The southern tier, anchored by Manchester and Nashua, contains the majority of the state’s 60,000 expansion adults, with most living within 60 minutes of major service centers. This concentration provides an administrative advantage compared to larger rural states. However, the North Country presents a stark contrast. Coos County has only 20 people per square mile compared to 775 per square mile in the southern tier, where geographic isolation compounds documentation challenges. The state that learned its systems weren’t ready in 2019 now has until January 2027 to ensure they’re ready again, though the federal timeline is fundamentally different than the state-driven attempt six years earlier.
H.R. 1, signed July 4, 2025, transformed work requirements from a state-option policy experiment into a federal mandate affecting 18.5 million expansion adults nationwide. The law requires 80 hours monthly of work, education, training, or qualifying community engagement activities, with semi-annual redetermination cycles replacing the annual reviews most states had been conducting. States face a January 1, 2027 implementation deadline, though good-faith extensions are available through December 31, 2028 for states demonstrating genuine progress toward compliance infrastructure.
CMS issued its first substantive implementation guidance on December 8, 2025, establishing several parameters that shape state planning. States must use reliable data sources to verify compliance before requesting documentation from enrollees, a data-first approach that privileges automated verification over member-initiated reporting. A 30-day cure period is required between initial non-compliance determination and coverage termination, during which members can demonstrate they were meeting requirements or qualify for exemptions. Congress allocated $200 million in implementation funding, half distributed equally across states and half proportional to affected population.
Two provisions create particular downstream pressure. Individuals who lose Medicaid coverage for work requirement non-compliance are barred from receiving premium tax credits on the ACA marketplace, meaning non-compliance creates a coverage void rather than a coverage transition. And the Trump administration rescinded Biden-era guidance on health-related social needs services in March 2025, while CMS has signaled it will not approve new or extend existing continuous eligibility waivers, narrowing the flexibility states had been using to stabilize enrollment.
For New Hampshire, this federal framework arrives with the weight of experience. The state’s 2019 work requirement attempt lasted barely four months before state officials acknowledged that approximately 17,000 residents faced imminent coverage loss, not because they weren’t working but because they couldn’t prove it. A federal court subsequently vacated CMS approval, joining the cascade of legal defeats that halted work requirements nationally. Now the same challenge returns, mandatory rather than optional, with implementation infrastructure requirements that exceed what the state attempted previously.
The 2019 Experience#
New Hampshire’s prior implementation collapsed before enforcement could begin, but the patterns that emerged offer essential lessons. The Granite Advantage program’s work requirement took effect in June 2019, with beneficiaries required to begin reporting work activities. Of approximately 50,000 expansion adults enrolled, about 25,000 were subject to requirements after automatic exemptions were applied. By July, only about 8,100 had successfully documented compliance. Nearly 17,000 residents faced potential coverage loss.
Governor Chris Sununu extended the compliance deadline to September 30, 2019, acknowledging that large numbers who had not reported reflected system failures rather than actual non-compliance. The state was not planning to impose penalties until after that date. But in July 2019, the same federal district court that had struck down Arkansas’s work requirements vacated CMS approval of New Hampshire’s program. The state’s implementation was permanently halted.
The pattern that emerged before the court ruling echoed Arkansas precisely: the vast majority of those who hadn’t reported were likely working or qualified for exemptions but couldn’t navigate the verification system. The no-wrong-door design intent had not translated into accessible implementation. Information systems were delayed. Enrollment churn created confusion even before enforcement began. Provider uncertainty about program continuation undermined the stability that treatment providers and employers needed to support compliance.
Judge James Boasberg found that CMS had failed to consider the program’s predictable effect of causing coverage losses. The court noted that New Hampshire’s own projections showed coverage would remain stable, but comments in the public record had detailed likely harm that CMS did not adequately address. The ruling cited evidence from SNAP work requirements in New Hampshire itself: when work requirements were reinstated in 2012, SNAP participation dropped by 5,480 adults within a year. The D.C. Circuit Court of Appeals affirmed the ruling in May 2020, and the Supreme Court ultimately remanded the case following the Biden administration’s withdrawal of work requirement approvals nationally.
State Budget Response and Political Positioning#
New Hampshire’s 2026-27 state budget, signed by Governor Kelly Ayotte on June 27, 2025, included several Medicaid-related provisions that shape the implementation landscape. The budget allocates funding for work requirements implementation, though detailed appropriations await federal guidance on system requirements. More significantly, the budget imposed new cost-sharing requirements on Granite Advantage enrollees.
Adults with incomes above 100 percent of the federal poverty level will pay monthly premiums of $60 to $100 based on family size, with families at higher income thresholds paying $190 to $270 monthly for Children’s Health Insurance Program coverage. Prescription copays increased to $4 for Granite Advantage enrollees at 100 percent FPL and above. These provisions create new financial barriers that may interact with work requirement compliance, as families managing premium payments while navigating documentation requirements face compounded administrative burden.
Senate Bill 134, introduced during the 2025 legislative session, directed the Department of Health and Human Services to resubmit a Section 1115 waiver to CMS seeking authority to reinstate work requirements. The bill required waiver submission by July 1, 2025, with annual reporting to the legislature on implementation status. The bill passed the Senate but was tabled by a House committee amid uncertainty about federal requirements and implementation costs. The passage of H.R. 1 in July rendered state waiver activity largely moot for the core work requirement, as federal law now mandates the policy directly.
The fiscal note accompanying SB 134 estimated implementation costs exceeding $2.5 million in fiscal years 2026 and 2027, though actual impact would depend heavily on federal guidance and the final shape of requirements. The note observed that approximately 65 percent of New Hampshire Medicaid beneficiaries are already working, suggesting that the affected population may be smaller than gross enrollment figures imply but that documentation barriers could still cause substantial harm.
Governor Ayotte has positioned New Hampshire as implementing what federal law requires while seeking to minimize coverage disruption. The state’s focus appears to be on system adequacy rather than policy resistance, recognizing that the 2019 experience demonstrated the consequences of inadequate preparation. However, the administration has not announced detailed exemption policies, verification infrastructure plans, or navigator investment strategies.
Population Characteristics and Implementation Challenges#
Approximately 60,000 adults are enrolled in the Granite Advantage Health Care Program, representing nearly 4 percent of the state’s total population of 1.4 million residents. The population skews younger than the national Medicaid expansion average, with roughly 30 percent under age 30. Gender distribution is approximately 52 percent female and 48 percent male. The racial composition is among the most homogeneous of any expansion state, with more than 90 percent of Granite Advantage enrollees identifying as white.
This homogeneity simplifies some implementation challenges, as language access and cultural competency concerns are less acute than in more diverse states. However, it also means New Hampshire’s experience offers limited guidance for states with substantial minority populations. The state’s tight labor market means the work requirement will function as a documentation test rather than an employment incentive. New Hampshire’s unemployment rate has consistently remained below 3 percent, among the lowest nationally. State data indicates that approximately 65 percent of Medicaid expansion adults are already working.
The critical implementation challenge is not inducing work but verifying it. For employed enrollees with stable W-2 employment, verification through Department of Employment Security wage records should be straightforward. For others, particularly those with multiple part-time employers, variable schedules, or self-employment arrangements, documentation becomes more complex. The service sector dominates New Hampshire employment, with retail, hospitality, and healthcare comprising major industries. These sectors often feature irregular schedules, tip-based income, and high turnover that complicate verification.
The Opioid Context#
New Hampshire experienced one of the nation’s most severe opioid epidemics, with overdose death rates exceeding national averages throughout the 2010s. Medicaid expansion, implemented in 2014, provided coverage for medication-assisted treatment precisely when the epidemic was intensifying. State data shows that overdose deaths have declined substantially since peak levels in 2017, with treatment access cited as a major contributing factor.
Governor Ayotte has highlighted New Hampshire’s progress in addressing the opioid epidemic, with drug-related deaths declining by more than 30 percent from 2017 levels. Medicaid expansion’s role in this progress creates particular sensitivity around work requirements. Individuals in recovery often qualify for substance use disorder exemptions, but proving ongoing treatment participation requires coordination between providers, treatment facilities, and state systems.
The state’s significant progress in addressing the opioid epidemic depends on maintained treatment access. Exemption processes must be designed so that people in treatment can prove it without destabilizing their recovery. Treatment providers must be equipped to document exemption eligibility. Relapse must be recognized as part of chronic illness management, not as grounds for coverage termination.
The Recovery Friendly Workplace Initiative, a state-supported program that encourages employers to support employees in recovery, creates an employment support infrastructure that could assist with work requirement compliance. However, the initiative’s voluntary nature and variable employer participation mean it cannot substitute for systematic verification infrastructure.
Rural North Country Considerations#
The North Country presents particular implementation challenges. Geographic isolation, limited internet access, seasonal employment patterns, and healthcare infrastructure fragility compound the documentation challenges. Coos County, the state’s largest by area and smallest by population, has minimal broadband infrastructure in many communities. Verification systems must accommodate paper and phone reporting.
Several North Country hospitals operate on thin margins, with Medicaid reimbursements comprising substantial portions of revenue. Coverage losses from work requirements could affect hospital sustainability in communities where alternative care options are hours away. Five Critical Access Hospitals serve the region, providing the only local acute care across vast territories. Thirteen Critical Access Hospitals statewide provide the backbone of rural healthcare delivery.
Seasonal employment patterns are common in the North Country, particularly in tourism and natural resource sectors. Someone working full-time during summer months may have minimal hours during winter, creating month-to-month compliance variation even among employed individuals. The state’s verification systems must accommodate these patterns or coverage churn will exceed actual employment changes.
Exemptions must recognize that living in a high-unemployment, low-opportunity area creates barriers that individual effort cannot overcome. The North Country’s limited public transportation, minimal childcare availability, and geographic isolation create structural barriers to both employment and documentation that urban-designed systems may not accommodate.
Federal Timing and State Preparation#
The December 8, 2025 CMS guidance provided states with clarity on several parameters but left substantial detail for future rulemaking. The requirement that states conduct member outreach between June 30 and August 31, 2026 creates a compressed timeline for system development, testing, and staff training. New Hampshire must design exemption policies, build verification infrastructure, develop member communication materials, train eligibility workers, and coordinate with MCOs and providers within this window.
The state’s small size creates both advantages and constraints. New Hampshire can theoretically implement more personalized approaches than massive states can contemplate. However, the state lacks the administrative infrastructure that larger states have built. New Hampshire operates no county-based Medicaid administration; all eligibility determination runs through the Division of Health and Human Services. Building work verification systems requires technology investment that larger states can spread across more members.
The data-first verification requirement offers New Hampshire an implementation pathway that could minimize member burden. If the state can establish automated data matching with Department of Employment Security wage records, educational enrollment systems, and SNAP work requirement compliance, many enrollees could receive deemed compliance without manual reporting. However, building these connections requires technical capacity and cross-agency coordination that takes time to develop.
MCO Coordination and Provider Engagement#
New Hampshire’s Medicaid expansion operates through managed care, with enrollees selecting between NH Healthy Families, AmeriHealth Caritas NH, and WellSense Health Plan. These MCOs will bear substantial responsibility for member education, compliance support, and care continuity during the transition. Their contracts should include work verification capabilities, exemption processing support, and member engagement for compliance assistance.
The state’s concentrated provider landscape enables institutional outreach partnerships. Major health systems like Dartmouth-Hitchcock, Elliot Health System, and Catholic Medical Center already serve most affected populations and could integrate compliance messaging into existing patient communication. However, provider participation requires clear guidance on documentation requirements and protected time for staff to support members navigating exemption processes.
Treatment providers for substance use disorders and mental health conditions play particularly critical roles. Their regular contact with vulnerable populations positions them to identify exemption eligibility and support documentation. However, providers require clear protocols, adequate reimbursement for administrative time, and assurance that supporting compliance does not compromise therapeutic relationships.
Projected Impacts and Coverage Loss Estimates#
Current projections suggest 17,000 to 19,000 Granite Staters could lose coverage under federal work requirements, consistent with the state’s 2019 experience before implementation was halted. The Urban Institute analysis underlying these estimates assumes documentation barriers will cause coverage loss among people who are actually working or exempt. The question for New Hampshire is whether its second implementation attempt can avoid the failures of the first.
The state’s high employment rate means most enrollees are already performing qualifying activities. The challenge is not inducing compliance but recognizing it. If verification systems function effectively and exemption processes are accessible, coverage losses could be substantially lower than projections suggest. Conversely, if system failures replicate 2019 patterns, losses could approach or exceed projections.
The marketplace exclusion provision creates particular concern. In 2019, individuals losing Medicaid coverage could transition to ACA marketplace plans with premium tax credits. Under H.R. 1, that option is foreclosed for work requirement non-compliance. This means coverage loss becomes complete loss of insurance access rather than coverage transition, raising the stakes for verification accuracy and exemption accessibility.
New Hampshire’s enhanced ACA subsidies expired at the end of 2025 under H.R. 1 provisions. This compounds the coverage void, as even individuals who could theoretically access marketplace coverage without work requirement barriers face higher premiums than under the enhanced subsidy regime. The combination creates a coverage cliff that the state’s systems must prevent rather than manage transitions across.
Critical Success Factors#
New Hampshire’s implementation success depends on several factors. First, verification infrastructure must accommodate the realities of service sector employment, seasonal work patterns, and self-employment arrangements common in the state’s economy. Traditional employer letters and pay stubs do not capture all legitimate work activity. The state’s wage record systems must be sophisticated enough to identify compliance across varied employment types.
Second, exemption processes must be accessible to populations with limited digital literacy, unstable housing, and health conditions that impair administrative capacity. Substance use disorder and mental health exemptions require particular attention, as the populations they protect often face the greatest barriers to documentation. Provider-supported attestation processes may prove more effective than member-initiated applications.
Third, the state must invest in navigation infrastructure that connects people to assistance before coverage is lost. The 30-day cure period creates an opportunity for intervention, but only if systems can identify non-compliance quickly and connect members with support. Community-based organizations, faith communities, and healthcare providers require training, resources, and coordination to function as navigation infrastructure.
Fourth, MCO accountability must include coverage retention metrics. If contracts create financial incentives for enrollment stability, MCOs will invest in compliance support. If contracts focus only on cost containment, MCOs may approach work requirements as opportunities to disenroll high-cost members rather than as challenges requiring active support.
Finally, the state must recognize that implementation is iterative. The first six-month reporting cycle will reveal system gaps, exemption processing bottlenecks, and verification challenges that initial design cannot anticipate. The state’s capacity to identify problems quickly and adjust systems accordingly will determine whether early coverage losses remain concentrated or cascade into broader disruption.
What New Hampshire Is Expected to Do#
New Hampshire will implement federal work requirements by January 2027 because federal law requires it. The state’s political leadership has not embraced work requirements as policy but recognizes the mandate. Implementation will likely emphasize automated verification through wage record matching, broad exemption categories, and MCO-based member support rather than aggressive enforcement.
The state’s 2019 experience functions as both warning and guide. Officials know what happens when systems aren’t ready, when member communication is inadequate, and when verification processes exceed administrative capacity. The question is whether 10 months of preparation time, combined with lessons from the first attempt and clearer federal guidance, will produce better outcomes.
The state that learned its systems weren’t ready in 2019 now has the benefit of experience but faces a compressed timeline and a federal mandate it cannot avoid. Whether New Hampshire’s second work requirement attempt produces better outcomes than its first will depend on execution quality, federal flexibility in waiver negotiations, and the state’s willingness to invest adequately in implementation infrastructure rather than assuming compliance will follow from policy imposition.
For the research community that documented failures nationally, New Hampshire’s implementation will be watched closely. If a small, relatively affluent state with one of the nation’s lowest unemployment rates, strong healthcare infrastructure, and institutional memory from prior implementation cannot avoid significant coverage losses, that signals fundamental problems with work requirement design rather than state-specific execution failures.