At times throughout the past year, following New Hampshire's Medicaid efforts has been somewhat like watching a mouse on an exercise wheel. A lot of activity but not really getting anywhere.
For example, the state announced in 2012 it would be transitioning its mostly fee-for-service Medicaid program to a managed care system. The process then ground to a halt when hospital systems balked at joining managed care networks, which is essential for such a system to work. In terms of Medicaid expansion under the Affordable Care Act, at one point in the state's legislative session it looked as if New Hampshire was set to expand its program up to 138 percent of the federal poverty level. Only then it wasn?t.

But after months of stalemates, fall 2013 is set to see a flurry of activity on the Medicaid front?with the transition to Medicaid managed care officially set to begin and a final decision on Medicaid expansion. Granted, this is New Hampshire we?re talking about?a small state nowhere near the size or with the uninsured troubles of a place like Texas or Florida. But a complete overhaul of a state's Medicaid delivery system coupled with the decision to expand Medicaid under the ACA is significant nonetheless.

First up will be the Oct. 15 final recommendation from a nine-member special commission on whether New Hampshire should expand its Medicaid program. Democratic Gov. Maggie Hassan and the Democratic-controlled House are in full support of expansion, which would add around 58,000 to the rolls. However, the Republican-controlled Senate balked during debate in June, and asked instead for further study?thus the special commission. If the commission recommends an expansion, which is the likely outcome, lawmakers will return this fall to pass such a measure to take effect in 2014. And while they may do it begrudgingly, it's likely Senate Republicans will go along with Medicaid expansion if the commission recommends it. Getting a small victory with the ?further study? option gives them political cover, and the pressure would simply be too intense for Republicans to vote otherwise. In addition, expansion would certainly open up more members for managed care plans, which are eager to get started after significant delays.

The plans will begin enrolling Dec. 1, 2013, almost a year later than originally planned The state awarded managed care contracts to Boston Medical Center HealthNet (doing business as Well Sense Health Plan), Centene Corp (New Hampshire Healthy Families) and Meridian Health Plan, good for a three-year term and worth a combined $2.27 billion in that time. In the request-for-proposals process, the state scored each insurer, with auto-assignment of beneficiaries who do not select a plan weighted toward the insurer with the highest technical score: BMC HealthNet.

BMC HealthNet will earn 50 percent of the auto-assigned beneficiaries, with Centene and Meridian splitting the rest, for 25 percent each. The state contracts focus on outcomes and reaching quality targets. In year one, quality incentives are built into the contracts for several measures, including member satisfaction, smoking cessation among pregnant women, and hospital readmissions. The New Hampshire drug benefit will be carved into the managed care plans, with each health plan's formulary and prior authorization criteria subject to approval by the state DHHS.

So while it's been a long and somewhat tortured journey for New Hampshire, the state is finally poised to both expand its Medicaid program and move into managed care. It may be that other states that have balked at Medicaid expansion will eventually follow suit in the next year. Better late than never, right?

Follow Ric Gross on Twitter at @RicGrossHLI

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