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

Last reviewed: 2026-09-10

The New Hampshire Department of Health and Human Services (DHHS), Health Facilities Administration (HFA), licenses congregate care settings under two distinct categories: Assisted Living Residence-Residential Care (ALR-RC) governed by He-P 804, and Assisted Living Residence-Supported Residential Health Care (ALR-SRHC) governed by He-P 805. Medicaid reimbursement for these services flows through the Choices for Independence (CFI) 1915(c) Waiver, administered by the Bureau of Elderly and Adult Services (BEAS).

Applicants must secure local municipal approvals for health, building, zoning, and fire ordinances before the state will process a licensure application. Once licensed, facilities enroll as providers in the NH Medicaid Management Information System (MMIS) to bill for waiver services, requiring an active license and a completed provider agreement with DHHS.

1. Service Definition and Scope

New Hampshire defines assisted living across two licensure levels based on resident acuity and evacuation capability. ALR-RC facilities provide personal care and supervision for residents who require minimal assistance and can self-evacuate.

ALR-SRHC facilities accommodate higher acuity needs, allowing for the availability of social or health services from trained or licensed individuals. These facilities can manage short-term convalescence and residents requiring mechanical transfer assistance, provided 24-hour complex nursing supervision is not required.

• ALR-RC Scope: Assistance with personal and social activities with a minimum of supervision or health care in a home-like setting.
• ALR-SRHC Scope: Provision of personal assistance at the supported residential care level, including short-term medical care for convalescing residents.
• Evacuation Requirement: ALR-RC residents must be capable of self-evacuation without assistance as defined by National Fire Protection Association (NFPA) 101.
• Medication Management: Both levels permit self-administration, self-directed administration, or administration by authorized personnel.
• Resident Assessment: Mandatory use of the DHHS CARES tool to determine compatibility with facility services.

2. Regulatory and Oversight Agencies

The New Hampshire Department of Health and Human Services (DHHS) oversees both the physical licensure of facilities and the administration of Medicaid waiver programs. The Health Facilities Administration (HFA) is the specific unit responsible for inspecting and licensing assisted living residences.

The Bureau of Elderly and Adult Services (BEAS) manages the Choices for Independence (CFI) Waiver, which funds Medicaid assisted living services. Provider enrollment and claims processing are handled through the NH MMIS portal.

• Licensing Agency: NH DHHS Health Facilities Administration (https://www.dhhs.nh.gov/doing-business-dhhs/licensing-certification/health-facilities-administration)
• Waiver Authority: NH DHHS Bureau of Elderly and Adult Services (https://www.dhhs.nh.gov/programs-services/adult-aging-care)
• Medicaid Enrollment: NH MMIS Provider Portal (https://nhmmis.nh.gov)
• Background Checks: NH Department of Safety (https://www.dos.nh.gov)

3. Gatekeeping Prerequisites: Who Can Even Apply

New Hampshire does not require a Certificate of Need (CON) or a Request for Proposals (RFP) process to open an assisted living facility. The state operates an open enrollment model for both licensure and Medicaid waiver participation.

The primary structural precondition that blocks an application from being accepted by HFA is the lack of local municipal approval. Applicants must prove compliance with local ordinances before the state will review the licensure packet.

• Certificate of Need: Not required for ALR-RC or ALR-SRHC facilities in New Hampshire.
• Local Ordinances: Applicants must submit documentation proving compliance with local health, building, zoning, and fire ordinances.
• Zoning Approval Form: A specific municipal sign-off, certificate of occupancy, or email indicating approval must be included with the initial application.
• Medicaid Moratoria: There are currently no closed networks or moratoria for CFI waiver assisted living providers.

4. Licensure and Certification Requirements

Prospective providers must submit a comprehensive application to the Health Facilities Administration, specifying whether they are applying under He-P 804 (ALR-RC) or He-P 805 (ALR-SRHC). The application must include detailed floor plans, policies, and the required fee.

Facilities must pass a physical inspection by HFA surveyors to ensure compliance with state administrative rules and the Life Safety Code before a license is issued.

• Application Form: DHHS Initial License Application for Health Care Facilities.
• Licensure Fee: $25.00 per licensed bed, submitted with the application.
• Rule Citations: He-P 804 for Residential Care; He-P 805 for Supported Residential Health Care.
• Life Safety Code: Compliance with NFPA 101 Life Safety Code, verified by the State Fire Marshal or local fire authority.
• Disclosure Summary: Required form detailing base rates, included services, and staff coverage provided to applicants prior to admission.

5. Medicaid Provider Enrollment

After obtaining an HFA license, facilities wishing to serve Medicaid participants must enroll in the NH Medicaid program. This is completed electronically through the NH MMIS Provider Portal.

Providers must sign a Medicaid Provider Agreement and link their enrollment to the Choices for Independence (CFI) Waiver to receive authorization for waiver services.

• System: NH MMIS Provider Portal operated by Conduent.
• Required Documentation: Active HFA license, W-9, and signed Medicaid Provider Agreement.
• Waiver Affiliation: Must specifically enroll to provide services under the CFI 1915(c) Waiver.
• Revalidation: Providers must revalidate their Medicaid enrollment every 5 years through the NH MMIS portal.

6. Staffing, Training and Background Checks

New Hampshire does not mandate strict numerical staffing ratios for assisted living facilities; instead, personnel levels are determined by the administrator based on resident acuity and facility size. However, facilities must employ a full-time administrator.

All staff and household members over the age of 18 must undergo comprehensive criminal background checks before employment or residence in the facility.

• Administrator Hours: Must employ a full-time administrator, defined as at least 35 hours per week.
• Administrator CEUs: Minimum of 12 hours of continuing education annually relating to facility operation and services.
• Background Checks: Criminal records check via the NH Department of Safety required for all employees and household members 18+.
• Disqualifying Offenses: Convictions for sexual assault, violent crime, fraud, abuse, neglect, or exploitation strictly bar employment.
• Staffing Ratios: No fixed numerical ratio; staffing must be sufficient to meet the needs identified in resident CARES tool assessments.

7. Documentation, Policies and Records

Facilities must maintain rigorous documentation to comply with HFA survey requirements. This includes detailed resident service agreements executed at admission and ongoing health assessments.

Surveyors frequently review personnel files and resident care plans to ensure services delivered match the documented needs and that all staff qualifications are verified on-site.

• Resident Service Agreement: Must be provided at admission, detailing services to be provided, costs, and relevant policies.
• CARES Tool: Standardized assessment completed prior to admission, every 6 months, or after any significant change in condition.
• Annual Health Assessment: Required annually unless a primary care provider specifies an alternative timeframe in writing.
• Service Documentation: Records must include the name of the individual providing services, date, brief summary of services, and care plans.
• Personnel Records: Must be maintained on-site, including background check results, training logs, and verification of qualifications.

8. Billing, Rates and Claims

Medicaid reimbursement under the CFI waiver covers the cost of personal care and supportive services, but federal rules prohibit Medicaid from paying for room and board in assisted living settings.

Claims are submitted electronically via the NH MMIS portal using specific HCPCS codes designated by the CFI waiver fee schedule.

• Room and Board: Not covered by Medicaid; residents pay via private funds or the Optional State Supplement (OSS).
• Billing System: Claims submitted electronically via the NH MMIS Provider Portal.
• Prior Authorization: CFI waiver services require authorization from BEAS case managers before claims can be paid.
• Rate Structure: Reimbursed according to the published DHHS CFI Waiver fee schedule based on authorized service levels.

9. Approval Sequence and Timeline

The approval process is sequential, beginning with local municipal sign-offs before state agencies become involved. HFA will not schedule a physical survey until the application and local approvals are fully processed.

Medicaid enrollment cannot begin until the HFA license is physically issued, making the state licensure timeline the primary driver of the overall approval sequence.

• Step 1: Secure local zoning, fire, and health ordinance approvals.
• Step 2: Submit HFA application with the $25/bed fee and required facility policies.
• Step 3: Pass HFA life safety and health inspections.
• Step 4: Receive ALR-RC or ALR-SRHC license from DHHS.
• Step 5: Submit Medicaid enrollment application via NH MMIS.

10. Common Denials and Survey Findings

HFA conducts pre-licensure and annual surveys. Deficiencies often stem from incomplete documentation, particularly regarding third-party providers or failure to update resident care plans.

Facilities also face citations for retaining residents whose acuity has exceeded the facility's licensure level, particularly regarding evacuation capabilities in ALR-RC settings.

• Documentation Gaps: Missing service notes or failure to document the specific agency/individual providing services in the resident record.
• Assessment Delays: Failure to complete the CARES tool every 6 months or immediately following a significant change in resident condition.
• Background Check Violations: Allowing staff to begin work before receiving official clearance from the NH Department of Safety.
• Evacuation Violations: Retaining residents in ALR-RC facilities who can no longer self-evacuate without assistance.

11. Key Contacts and Resources

Prospective providers should utilize the DHHS Health Facilities Administration for all licensure inquiries and the NH MMIS portal for Medicaid enrollment support.

The state's administrative rules (He-P 804 and He-P 805) are the definitive legal standards for operating these facilities.

• Health Facilities Administration: https://www.dhhs.nh.gov/doing-business-dhhs/licensing-certification/health-facilities-administration
• NH MMIS Provider Portal: https://nhmmis.nh.gov
• Bureau of Elderly and Adult Services: https://www.dhhs.nh.gov/programs-services/adult-aging-care
• NH Administrative Rules (He-P 800): https://www.gencourt.state.nh.us/rules/state_agencies/he-p800.html

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