Study committee hears competing views on managed long‑term care, D‑SNP and county funding risks

The legislature's study committee on long‑term managed care on Oct. 28 heard providers, county nursing‑home administrators and Department of Health and Human Services staff debate how — and whether — to move long‑term services and supports (LTSS) into managed care.

The committee's chair, state Representative Jim Kofalt, opened the meeting by approving minutes and noting the committee's schedule of stakeholder testimony.

Granite State Home Health and Hospice Association CEO Kelly Ann Totten said the home‑care sector in New Hampshire is highly varied and fragile, and urged inclusive, methodical planning before any transition. Totten told the committee that "no 2 home care agencies are the same," describing a mix of post‑acute Medicare agencies, private‑pay providers and Medicaid Choices for Independence (CFI) vendors that operate under different licensure rules. She warned that some smaller agencies "lack the administrative and technology support to quickly respond to changes from a payer perspective," and said workforce pressures remain acute after earlier rate increases have begun to erode amid inflation and competing employer wages.

Totten also flagged a proposed Centers for Medicare & Medicaid Services cut of about 9% to the Medicare home‑health payment rate and said, if enacted, it could force agencies to reduce service areas or discontinue community benefit offerings such as clinics, foot care, caregiver education and dementia support. The association recommended a phased, cautious approach with regional pilots, workforce investments tied to wage stabilization and ongoing frontline feedback during planning.

Amy Moore, board chair of the Home Care, Hospice & Palliative Care Alliance, echoed those concerns, saying in part that the industry has experienced "death by a thousand cuts" over many years and that transitions should allow time to avoid unintended service losses.

Representing the New Hampshire Association of Counties, Craig Labore and David Ross said counties support shifting appropriate care to home‑and‑community settings but raised a central fiscal objection: moving LTSS into managed care would, they said, eliminate access to supplemental payment programs the counties and some providers currently receive. Labore told the committee that the Medicaid final rule of 2016 "expressly prohibits supplemental payment programs to providers enrolled in a managed services and supports model," and that the loss of the Medicaid Quality Incentive Payment (MQIP) and county proportionate share (ProShare) funding would be a roughly $60,000,000 revenue hit to county facilities.

County officials pointed to recent DHHS data cited in the governor's budget showing nursing‑home reliance falling to 51.7% in December 2024 (down from about 70% in 2017) and noted a moratorium on adding nursing‑home beds. They said the state has been moving toward more community‑based care, but cautioned that removing supplemental revenue streams or reducing direct provider reimbursement would undercut the ability to expand community capacity.

DHHS staff, including State Medicaid Director Henry Littman and Bureau Chief Wendy Altman, described two possible managed‑care approaches the department has studied: dual eligible special needs plans (D‑SNP), which align Medicare Advantage and Medicaid benefits for people eligible for both programs, and the federal PACE (Program of All‑Inclusive Care for the Elderly) model. Altman said ATI Advisory completed feasibility work and that New Hampshire has about 31,000 dual‑eligible residents; roughly 8,000 of those receive long‑term services and supports today. DHHS noted that D‑SNPs can be structured to include or exclude LTSS and that PACE may be feasible in denser, urbanized parts of the state but is less suitable in rural regions because of PACE's requirement for centralized physical sites and transportation.

Littman warned that New Hampshire's Medicaid program is small relative to other states (roughly 180,000 total enrollees) and that managed‑care organizations typically prefer larger membership pools — a consideration for statewide versus regional rollout. He also said the rural health transformation funding in OB 3 is aimed at transformational investments (technology, workforce development, telehealth) and "can't be used for rates," and that the application window to access that five‑year fund is short.

Committee members asked about implementation paths, and DHHS staff said regional waivers are possible but that careful planning is important. DHHS officials said a D‑SNP that coordinates Medicare and Medicaid benefits has the potential to increase home‑and‑community use, citing Indiana as an example, but acknowledged open questions about how managed‑care payments would flow to providers and how to protect existing supplemental funding relied upon by county homes.

Kofalt closed the meeting after members agreed to defer extended committee deliberation until additional stakeholders appear at the next session. The committee asked stakeholders to continue submitting materials for review.

For follow‑up: DHHS and ATI Advisory have produced feasibility materials the department said it will share; county officials asked for further financial analysis of impacts to MQIP and ProShare; home‑care associations said implementation timelines should include workforce stabilization measures and pilot testing before a broader rollout.