I. (a) The commissioner shall apply for any necessary waivers and state plan amendments to implement a 5-year demonstration program beginning on January 1, 2019 to create the New Hampshire granite advantage health care program which shall be funded exclusively from non-general fund sources, including federal funds. The commissioner shall include in an application for the necessary waivers submitted to the Centers for Medicare and Medicaid Services (CMS) a waiver of the requirement to provide 90-day retroactive coverage and a state plan amendment allowing state and county correctional facilities to conduct presumptive eligibility determinations for incarcerated inmates to the extent provided under federal law. To receive coverage under the program, those individuals in the new adult group who are eligible for benefits shall choose coverage offered by one of the managed care organizations (MCOs) awarded contracts as vendors under Medicaid managed care, pursuant to N.H. Rev. Stat. § 126-A:5, XIX(a). The program shall make coverage available in a cost-effective manner and shall provide cost transparency measures, and ensure that patients are utilizing the most appropriate level of care. Cost effectiveness shall be achieved by offering cash incentives and other forms of incentives to the insured by choosing preferred lower cost medical providers. Loss of incentives shall also be employed. MCOs shall employ reference-based pricing, cost transparency, and the use of incentives and loss of incentives to the Medicaid and newly eligible population. For the purposes of this subparagraph, “reference-based pricing” means setting a maximum amount payable for certain medical procedures.
(b) The department shall ensure through managed care contracts that MCOs incorporate measures to promote continuity of coverage, including, but not limited to, assisting over income participants in applying for coverage on the federal marketplace in New Hampshire and maintaining care and case management during the pendency of such application.
(c) The MCOs shall promote personal responsibility through the use of incentives, loss of incentives, and case management to the greatest extent practicable.
(d) Prior to submitting the waiver or state plan amendment to CMS, the commissioner shall present the waiver or state plan amendment to the governor and the fiscal committee of the general court for approval. The program shall not commence operation until such waivers or state plan amendments have been approved by CMS. All necessary waivers and state plan amendments shall be submitted by June 30, 2018. If all waivers necessary for the program are not approved by December 1, 2018, the commissioner shall immediately notify all program participants that the program will be terminated in accordance with the federally required Special Terms and Conditions No. 11-W-003298/1.
(e) In order to combat the opioid and heroin crisis facing New Hampshire, the department shall establish behavioral health rates sufficient to ensure access to, and provider capacity for, all behavioral health services including, as appropriate, establishing specific substance use disorder services rate cells for inclusion into capitated rates for managed care.
(f) Any person transitioning from the premium assistance program to the program shall not lose coverage due solely to the transition, which shall be for a period of at least 90 days. All MCOs shall honor all preexisting authorizations for care plans and treatments for all program participants for a period of not less than 90 days after enrollment.
(g)(1) The commissioner shall include in MCO contracts with the state clinically and actuarially sound incentives designed to improve care quality and utilization and to lower the total cost of care within the Medicaid managed care program. The commissioner shall also include in the MCO contract provisions an obligation for the MCO to include provider alignment incentives to leverage the combined efforts of the parties to achieve the purposes of the incentives. Preferential auto-assignment of newly eligible members, shared incentive pools, and differential capitation rates are among the options for incentives the commissioner may employ to achieve improved performance. Initial areas to improve care quality and utilization and to lower the total cost of care may include, but are not limited to:
(A) Appropriate use of emergency departments relative to low acuity non-emergent visits.
(B) Reduction in preventable admissions and 30-day hospital readmission for all causes.
(C) Timeliness of prenatal care and reductions in neonatal abstinence births.
(D) Timeliness of follow-up after a mental illness or substance use disorder admission.
(E) Reduction of polypharmacy resulting in drug interaction harm.
(2) The commissioner shall include in MCO contracts actuarially appropriate rebate provisions for failure to implement contractually agreed upon incentive measures.
(3) The commissioner shall establish for the managed care program beginning on July 1, 2019 and thereafter a minimum medical loss ratio that is actuarially sound and that encourages cost efficiency in the delivery of care to the entire Medicaid population. Any surplus funds generated from the MCOs managing the cost of their services below the established minimum medical loss ratio for the beneficiaries of the program shall be transferred to the fund and shall be included in the calculation of the remainder amount.
(h) Savings generated as a result of individuals disenrolled from the program for failing to meet the work and community engagement requirement shall not be included in any calculation submitted to CMS to establish federal budget neutrality of any waiver issued for the program.
(i) Consistent with the state plan amendment submitted by the department and approved by CMS, all contracts between a Medicaid managed care organization and a federally qualified health care center, as defined in section 1905(1)(2)(B) of the Social Security Act, 42 U.S.C. § 1396d(1)(2)(B), providing services in geographic areas served by the plan, shall reimburse each such center for such services as provided in 42 U.S.C. § 18022(g).
II. (a) To receive benefits under this section and to the extent allowed by federal law, the individual shall:
(1) Provide all necessary information regarding financial eligibility, assets, residency, citizenship or immigration status, and insurance coverage to the department in accordance with rules, or interim rules, including those adopted under RSA 541-A;
(2) Inform the department of any changes in financial eligibility, residency, citizenship or immigration status, and insurance coverage within 10 days of such change; and
(3) At the time of enrollment acknowledge that the program is subject to cancellation upon notice.

[Paragraph II(b) effective on the date of certification that 42 U.S.C. § 1396a(e)(14)(c) has been repealed or amended to permit the application of an asset test.]

(b) If allowed by federal law, all resources which the individual and his or her family own shall be considered to determine eligibility under this paragraph, including cash, bank accounts, stocks, bonds, permanently unoccupied real estate, and trusts. The home in which the individual resides, furniture, and one vehicle owned by the individual applying for benefits shall be or excluding the individual’s household resources, the total countable resources equal or fall below excluding the individual’s household’s resources, the total countable resources equal or fall below $25,000, he or she shall be considered asset eligible.
III. (a) Newly eligible adults who are unemployed shall be eligible to receive benefits under this paragraph if the commissioner finds that the individual is engaging in at least 100 hours per month based on an average of 25 hours per week in one or more work or other community engagement activities, including self-employment, as follows:
(1) Unsubsidized employment including by nonprofit organizations.
(2) Subsidized private sector employment.
(3) Subsidized public sector employment.
(4) On-the-job training.
(5) Job skills training related to employment, including credit hours earned from an accredited college or university in New Hampshire. Academic credit hours shall be credited against this requirement on an hourly basis.
(6) Job search and job readiness assistance, including, but not limited to, persons receiving unemployment benefits and other job training related services, such as job training workshops and time spent with employment counselors, offered by the department of employment security. Job search and job readiness assistance under this section shall be credited against this requirement on an hourly basis.
(7) Vocational educational training not to exceed 12 months with respect to any individual.
(8) Education directly related to employment, in the case of a recipient who has not received a high school diploma or a certificate of high school equivalency.
(9) Satisfactory attendance at secondary school or in a course of study leading to a certificate of general equivalence, in the case of a recipient who has not completed secondary school or received such a certificate.
(10) Community service or public service.
(11) [Repealed.]
(12) Participation in substance use disorder treatment or recovery activities and/or mental health treatment.
(b) If an individual in a family receiving benefits under this paragraph fails to comply with the work or community engagement activities required in accordance with this paragraph, the assistance shall be suspended. The commissioner shall adopt rules under N.H. Rev. Stat. Chapter 541-A to determine good cause and other exceptions to termination. Any rules proposed under this subparagraph shall be submitted to the fiscal committee of the general court, which shall review the rules prior to submission to the joint legislative committee on administrative rules and make recommendations to the commissioner regarding the rules. An individual may apply for good cause exemptions which shall include, at a minimum, the following verified circumstances:
(1) The beneficiary experiences the birth or death of a family member living with the beneficiary.
(2) The beneficiary experiences severe inclement weather, including a natural disaster, and therefore was unable to meet the requirement.
(3) The beneficiary has a family emergency or other life-changing event such as divorce.
(4) The beneficiary is a victim of domestic violence, dating violence, sexual assault, or stalking consistent with definitions and documentation required under the Violence Against Women Reauthorization Act of 2013 under 24 C.F.R. § 5.2005 and 24 C.F.R. § 5.2009, as determined by the commissioner pursuant to rulemaking under RSA 541-A.
(c) This paragraph shall only apply to those considered able-bodied adults as described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act of 1935, as amended, 42 U.S.C. § 1396a(a)(10)(A)(i).
(d) This paragraph shall not apply to:
(1) A person who is unable to participate in the requirements under subparagraph (a) due to illness, incapacity, or treatment, including inpatient treatment, as certified by a licensed physician, an advanced practice registered nurse (APRN), a licensed behavioral health professional, a licensed physician assistant, a licensed alcohol and drug counselor (LADC), or a board-certified psychologist. The physician, APRN, licensed behavioral health professional, licensed physician assistant, LADC, or psychologist shall certify, on a form provided by the department, the duration and limitations of the disability.
(2) A person participating in a state certified drug court program, as certified by the administrative office of the superior court.
(3) A parent or caretaker where the required care of an individual who may or may not reside in the household is considered necessary by a licensed physician, APRN, board-certified psychologist, physician assistant, or licensed behavioral health professional who shall certify the duration that such care is required.
(4) A custodial parent or caretaker of a dependent child through 12 years of age or a child with developmental disabilities who is residing with the parent or caretaker; provided that the exemption shall only apply to one parent or caretaker in the case of a 2-parent household where responsibility for the child the exemption is based on is shared by the 2 parents or caretakers.
(5) Pregnant women.
(6) A beneficiary who has a disability as defined by the Americans with Disabilities Act (ADA) , section 504 of the Rehabilitation Act, or section 1557 of the Patient Protection and Affordable Care Act with or without an accommodation; or who has an immediate family member in the home with a disability under federal disability rights laws and who is unable to meet the requirement for reasons related to the disability of that family member, or the beneficiary or an immediate family member who is living in the home or the beneficiary experiences a hospitalization or serious illness.
(7) Beneficiaries who are identified as medically frail, under 42 C.F.R. § 440.315(f), and as defined in the alternative benefit plan and in the state plan and who are certified by a licensed physician or other medical professional to be unable to comply with the work and community engagement requirement as a result of their condition as medically frail. The department shall require proof of such limitation annually, including the duration of such disability, on a form approved by the department.
(8) Any beneficiary who is in compliance with the requirement of the Supplemental Nutritional Assistance Program (SNAP) and/or Temporary Assistance to Needy Families (TANF) employment initiatives.
(9) Any beneficiary who is homeless as defined by the McKinney-Vento Homeless Assistance Act of 1987, 42 U.S.C. § 11301 et seq.
(e) The commissioner shall adopt rules under N.H. Rev. Stat. Chapter 541-A pertaining to the community engagement requirement. Any rules proposed under this subparagraph shall be submitted to the fiscal committee of the general court, which shall review the rules prior to submission to the joint legislative committee on administrative rules and make recommendations to the commissioner regarding the rules. The rules shall be consistent with the terms and conditions of any waiver issued by the Centers for Medicare and Medicaid Services for the program, provided that any waiver issued by the Centers for Medicare and Medicaid Services is not unreasonably inconsistent with any provision of this chapter, and shall address, at a minimum, the following:
(1) Enrollment, suspension, and disenrollment procedures in the program.
(2) Verification of compliance with community engagement activities.
(3) Verification of exemptions from participation.
(4) Opportunity to cure and re-activation following noncompliance, including not being barred from re-enrollment.
(5) Good cause exemptions.
(6) Education and training of enrollees.
(7) Annual certification of medical frailty pursuant to 42 C.F.R. § 440.315(f), including proof and duration of such condition on a form supplied by the department.
IV. The commissioner shall implement the work and community engagement requirement under paragraph III beginning January 1, 2019 in accordance with the terms and conditions of any waiver approved by CMS. The waiver request submitted by the commissioner shall be consistent with all the terms of this chapter. In the event that the final approved waiver is inconsistent with any of the terms of this chapter, the commissioner shall provide written notification to the governor, the speaker of the house of representatives, and the president of the senate, informing them of the differences between the terms of this chapter and the approved waiver. Verification of qualifying activities, exemptions, and enrollee status shall be accomplished in the following manner:
(a) MCOs under contract with the department shall share enrollee reported information regarding the work and community engagement requirement status obtained through standard contract activities including enrollment, outreach activities, and enrollee care management. The MCOs shall work collaboratively with the department and any outside contractor in encouraging and monitoring work and community engagement activities.
(b) For the period of January 1, 2019 through June 30, 2020 only, the department shall verify enrollee status to the greatest extent practicable through the verification of enrollee and MCO reported status and information, including information from the eligibility file. Enrollees shall be required to report information regarding their qualifying activities, exemptions, enrollee status, and changes in their status to the department in accordance with the department’s rules.
(c) No later than January 1, 2019, the commissioner shall submit to the governor, the president of the senate, and the speaker of the house of representatives a plan for the implementation of a fully automated verification system that utilizes state and commercial data sources to assess compliance with all work and community engagement activities beginning on July 1, 2020. The plan shall provide an option to hire a third party vendor to manage the automated verification system.
V. A person shall not be eligible to enroll or participate in the program, unless such person verifies his or her United States citizenship by 2 forms of identification and proof of New Hampshire residency by either a New Hampshire driver’s license or a nondriver’s picture identification card issued pursuant to N.H. Rev. Stat. § 260:21.
VI. No person, organization, department, or agency shall submit the name of any person to the National Instant Criminal Background Check System (NICS) on the basis that the person has been adjudicated a “mental defective” or has been committed to a mental institution, except pursuant to a court order issued following a hearing in which the person participated and was represented by an attorney.
VII. For any person determined to be eligible and who is enrolled in the program, the MCO shall support the individual to arrange a wellness visit with his or her primary care provider, either previously identified or selected by the individual from a list of available primary care providers. The wellness visit shall include appropriate assessments of both physical and mental health, including screening for depression, mood, suicidality, and unhealthy substance use, for the purpose of developing a health wellness and care plan.
VIII. Any person receiving benefits from the program shall be responsible for providing information regarding his or her change in status or eligibility, including current contact information. The commissioner shall adopt rules, under RSA 541-A, pertaining to the opportunity to cure and for re-activation following noncompliance. Any rules proposed under this subparagraph shall be submitted to the fiscal committee of the general court, which shall review the rules prior to submission to the joint legislative committee on administrative rules and make recommendations to the commissioner regarding the rules.
IX. The commissioner shall, as expeditiously as possible, submit to the Centers for Medicare and Medicaid Services an amendment to the waiver for approval of a revised waiver of retroactive eligibility permitting coverage for the 45-day period immediately preceding the determination of eligibility for all persons insured in the program.
X. The commissioner shall waive the application of the work and community engagement requirement in subparagraph III(a) or the suspension from coverage for noncompliance for any period of time up to but not after July 1, 2021 upon a finding of one or more of the following circumstances that impact a substantial number of program members who are mandatory for the requirement:
(a) The inability to communicate verbally and in writing and directly counsel all members who are mandatory for the requirement and not already exempted or are in compliance in accordance with the rules of the work and community engagement requirement adopted under 541-A.
(b) The unavailability of qualifying activities in any region of the state that may result in a disproportionate impact upon program members located elsewhere.
(c) The impact of seasonal employment opportunities on the ability of members to achieve the minimum hours for qualifying activities.
(d) The inability to achieve the minimum hours of qualifying activities after taking into account all applicable exemptions despite good faith efforts to comply.
(e) The unavailability of transportation and other supports for members who are not eligible for assistance through granite workforce.
(f) Other unforeseen circumstances that impact the administration and verification of the program and that more likely than not would cause members to be suspended from the program.
XI. The commissioner shall notify the governor, the president of the senate and the speaker of the house of representatives in writing no later than 7 days after making a finding under paragraph X with a detailed explanation as to the basis of the findings, the steps the department can and is taking to address the circumstances that gave rise to the findings, and any recommendations regarding how the suspension of the requirement may be lifted and the compliance provisions of the program resumed. The commissioner may submit an amendment to the program waiver (CMS # 11-W-00298/1) to incorporate the authority to waive the suspension of coverage consistent with this provision, to the extent required by the Centers for Medicare and Medicaid Services.