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New Hampshire - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In New Hampshire, Assisted Living is licensed by the Department of Health and Human Services (DHHS) Health Facilities Administration (HFA) under two primary categories: Assisted Living Residence-Residential Care (ALR-RC) for lower-acuity needs, and Assisted Living Residence-Supported Residential Health Care (ALR-SRHC) for residents requiring nursing home-level care. Medicaid reimbursement for services provided in these settings is administered primarily through the Choices for Independence (CFI) Waiver.

The single biggest structural barrier to entry in New Hampshire is the mandatory physical plant and life safety approval process, which requires local municipal zoning clearance and State Fire Marshal approval before HFA will even process the architectural plans or issue a license. Furthermore, because New Hampshire operates a managed care model for Medicaid, obtaining a state license and a Medicaid ID is insufficient for reimbursement; providers must successfully credential and contract with the state's three Medicaid Care Management (MCO) plans to receive payment for CFI waiver enrollees.

1. Service Definition and Scope

New Hampshire defines assisted living through distinct licensure tiers based on the level of care provided. Assisted Living Residence-Residential Care (ALR-RC) facilities provide housing, supervision, and assistance with activities of daily living (ADLs). Assisted Living Residence-Supported Residential Health Care (ALR-SRHC) facilities provide a higher level of medical monitoring and nursing care, allowing them to retain residents who meet nursing facility level of care.

Under the Medicaid Choices for Independence (CFI) Waiver, reimbursement covers the personal care, homemaker, and supportive services delivered within the facility. Medicaid regulations strictly prohibit the use of waiver funds to pay for the resident's room and board, which must be covered by the resident's private income or state supplemental assistance.

2. Regulatory and Oversight Agencies

The New Hampshire Department of Health and Human Services (DHHS) is the umbrella agency responsible for both facility licensure and Medicaid administration. Within DHHS, the Health Facilities Administration (HFA) is the regulatory body that processes applications, conducts life safety and health inspections, and issues licenses.

The Bureau of Elderly and Adult Services (BEAS) manages the programmatic aspects of the CFI Waiver. Meanwhile, the actual administration of Medicaid benefits and provider network management is delegated to the three Managed Care Organizations (MCOs) operating under the NH Medicaid Care Management (MCM) program.

3. Gatekeeping Prerequisites: Who Can Even Apply

New Hampshire does not have a Certificate of Need (CON) program, nor are there state-imposed moratoria on new assisted living facilities. However, strict structural prerequisites block an application from moving forward. An applicant cannot receive a license without first securing local municipal zoning approval, a local certificate of occupancy, and clearance from the State Fire Marshal.

Additionally, HFA requires a formal Physical Plant Review of architectural plans before any construction or renovation begins. For Medicaid reimbursement, providers face a secondary gate: they must secure network contracts with the state's MCOs. If an MCO determines its network is adequate, it may decline to contract with a new facility, effectively blocking Medicaid revenue.

4. Licensure and Certification Requirements

Prospective providers must submit a comprehensive application to the HFA, which includes the application fee, ownership disclosures, and detailed facility policies. The facility must comply with the specific physical environment standards outlined in He-P 804 or He-P 805, depending on the licensure tier.

Before a license is issued and residents can be admitted, HFA conducts an initial on-site survey. This includes a life safety code inspection to verify fire safety compliance and a health inspection to ensure administrative and clinical policies are properly implemented.

5. Medicaid Provider Enrollment

Once the HFA license is secured, the facility must enroll as a New Hampshire Medicaid provider through the NH MMIS Health Enterprise Portal. The facility must enroll under the specific taxonomy code for Assisted Living or Residential Care and provide its NPI, EIN, and HFA license number.

After the state issues a NH Medicaid ID, the provider is not yet ready to bill. The facility must then complete the credentialing process with the three MCOs (NH Healthy Families, WellSense, AmeriHealth Caritas) by submitting a CAQH form or the specific MCO enrollment roster.

6. Staffing, Training and Background Checks

New Hampshire sets strict qualifications for facility administrators and staff. Under He-P 804 and 805, the Administrator must be at least 21 years old and possess a specific combination of education and experience in health care or human services. Administrators must also complete a minimum of 12 hours of continuing education annually.

All personnel must undergo comprehensive background checks before having direct contact with residents. This includes a criminal history check through the NH State Police and a registry check through the Bureau of Elderly and Adult Services (BEAS) to ensure no history of abuse, neglect, or exploitation.

7. Documentation, Policies and Records

Facilities must maintain comprehensive administrative and resident care policies as mandated by He-P 804 and 805. This includes a detailed admission agreement that clearly outlines the services provided, the fee structure, and the criteria for involuntary discharge or eviction.

Resident records must contain individualized care plans that are updated semi-annually or whenever there is a significant change in the resident's condition. Facilities must also maintain strict medication administration records (MARs) and a written emergency preparedness and disaster plan.

8. Billing, Rates and Claims

Medicaid billing for the CFI waiver is not submitted directly to the state MMIS for most enrollees; instead, claims are routed to the resident's assigned MCO. Providers bill a per diem rate based on the specific tier of care authorized in the resident's BEAS comprehensive assessment.

Because Medicaid does not cover room and board, facilities must bill the resident directly for these costs. Residents often use their Social Security income or State Supplement Program (SSP) funds to cover the room and board portion of their monthly bill.

9. Approval Sequence and Timeline

The approval process is highly sequential and cannot be rushed. It begins with securing local zoning and State Fire Marshal approvals, followed by the HFA physical plant review. Once architectural plans are approved and construction/renovation is complete, the formal licensure application is submitted.

After HFA conducts the initial survey and issues the license, the facility applies for a NH Medicaid ID via the MMIS portal. Finally, the provider undergoes MCO credentialing. The entire end-to-end process typically takes 6 to 12 months, heavily dependent on construction timelines and MCO credentialing backlogs.

10. Common Denials and Survey Findings

During initial and renewal surveys, HFA frequently cites facilities for life safety code violations, such as improper fire door operation or blocked egresses. Clinical citations often involve inadequate Medication Administration Records (MARs) or allowing unauthorized staff to assist with medications.

Medicaid enrollment and reimbursement delays usually stem from attempting to bill before MCO credentialing is fully complete, or failing to obtain the required prior authorization from the MCO based on the BEAS care plan.

11. Key Contacts and Resources

The primary regulatory contact is the NH DHHS Health Facilities Administration (HFA), which handles all licensing and physical plant inquiries. For Medicaid enrollment, providers must utilize the NH MMIS Health Enterprise Portal and contact Provider Relations for technical assistance.

Questions regarding the Choices for Independence (CFI) Waiver structure and resident assessments should be directed to the Bureau of Elderly and Adult Services (BEAS).

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