New Hampshire is among a handful of states that began removing people from Medicaid this month, but its efforts to ensure a smooth transition began nearly three years ago.

After barring states from kicking people off the program during the COVID-19 pandemic, the federal government is now requiring states to remove those who no longer qualify — either because their incomes are too high or they’ve moved, for example.

The review, also called "redetermination" or "unwinding," is expected to leave millions over the next year without Medicaid. In New Hampshire, Medicaid Director Henry Lipman said the state began planning in July 2020 rather than waiting until "the flood was up to the door."

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Those efforts included a massive public awareness campaign last year to encourage enrollees to voluntarily start the redetermination process early.

"Over 25% of the redeterminations that needed to be done were done in advance," he said. "That was big. It allowed us more bandwidth to help people."

The state sent thousands of "friendly reminders" printed on pink paper before switching to more urgent yellow notices to provide a frame of reference for providers and others who might come in contact with enrollees. It also has been working with advocacy groups, the insurance department and federally funded health care navigators to steer people into other coverage, including employer plans, Medicare and former President Barack Obama’s Affordable Care Act.

In March, the state reassessed eligibility for roughly 21,000 people. Seventy percent were deemed no longer eligible, Lipman said. Of those, 56% were referred to the federal marketplace plans, he said.

"I describe it sort of like a chapter book. The pink and yellow notices were sort of the prologue, and now we’re in Chapter 1 and people are transitioning," he said. "What we’re trying to do is say, ‘Just because you may have gotten a decision that you’re not eligible, we have lifeboats to help get you coverage.’"

Heather Stockwell, a health care campaigns organizer with the Rights & Democracy Project, has been leading monthly Zoom calls for Medicaid recipients, spreading the word by attending community events, handing out flyers on street corners and leaving information at social service organizations around the state. Those who have gone through the redetermination process have found it fairly arduous, she said.

"One of the biggest complaints that I hear is about the amount of redundant paperwork," she said. "When somebody’s making less than $10,000 a year, that is not really necessary, in my opinion. They’re struggling enough."

The state expects the number of people deemed ineligible to drop in the coming months because the initial focus has been on people who have not used their benefits for the past year, are no longer in touch with the department, or are known to no longer qualify financially. Children, people in long-term care and others considered more vulnerable will be approached later in the unwinding process.

In Rochester, Amy Shaw said she and her husband recently lost their Medicaid coverage after his pay increased by 50 cents per hour to $17 per hour. She previously worked as a social worker but now cares for their two daughters with special needs while her husband works for an auto parts store.

Suddenly, instead of a $3 copay, she was billed $120 for a cancer screening ordered by her doctor. Meanwhile, their rent increased by 40%, and the cost of food, utilities and other essentials remain high.

"It just stinks when you don’t make that much over," she said. "Even though COVID might be down, the prices are still up."

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Zandra Rice Hawkins, executive director of the advocacy group Granite State Progress, praised the state, navigators and other advocacy groups for what has so far been a smooth process for those receiving notices. But she worries about others who have been overlooked, including those with unstable housing who have their belongings and important paperwork in storage units.

"We have a lot of people who have had to switch housing because of the loss of a job, and that’s probably why some of those folks ended up in Medicaid enrollment to begin with," she said.

Rice Hawkins said she is particularly worried about those who may have been disenrolled in other aid programs and thus are no longer in contact with state agencies.

"It’s particularly important that we pay attention to those who maybe are getting to a more stable place but are still pretty vulnerable," she said. "This could potentially throw them off their health coverage."