New Hampshire runs long-term care differently than its neighbors, and the differences change what you should tell a family. The state operates a home and community-based alternative called Choices for Independence rather than treating a nursing facility as the default. Its counties bear a share of the non-federal cost of nursing facility Medicaid, which is why county nursing homes remain a live part of the landscape rather than a historical artifact. And New Hampshire is one of the remaining section 209(b) states, which means the resource figures your colleague in Massachusetts quotes may simply not apply.
Against that, the money problem is the same one everywhere. Recent published cost-of-care surveys put New Hampshire’s median semi-private nursing facility rate in the range of roughly $12,000 to $13,500 per month — among the higher figures in the country — while a Medicaid determination has 45 days under federal rules and long-term care applications routinely take longer. Families fill that gap by liquidating, and the life insurance policy is usually the asset they handle worst.
You are allowed to tell them the option exists. You are not allowed to name a company, rank the choices, or accept anything of value. This guide covers 42 C.F.R. 482.43, the three-midnight and 100-day mechanics, the MOON, New Hampshire’s eligibility timing, and what RSA chapter 408-D actually requires of a legitimate transaction.
In This Article
- The New Hampshire landscape: CFI, county homes, and 209(b)
- Your obligations under 42 C.F.R. 482.43
- The MOON and the three-midnight rule
- Days 21 to 100, and the benefit-period reset
- The eligibility gap, and how families fill it
- RSA 408-D and what a legitimate transaction looks like
- Documentation that protects you, and the compensation rule
- Frequently Asked Questions
The New Hampshire landscape: CFI, county homes, and 209(b)
Long-term care Medicaid in New Hampshire runs through the Department of Health and Human Services, with the Bureau of Elderly and Adult Services administering services for older adults. Choices for Independence is the state’s home and community-based waiver, and it is worth naming to families early rather than presenting a facility as the only destination. For a patient who can be supported at home with services, CFI is frequently both the better clinical outcome and the cheaper one.
New Hampshire is unusual in that its counties share in the non-federal cost of nursing facility Medicaid. That is why county-operated nursing homes are still a substantial part of the bed supply and why county administrators pay attention to these cases in a way that administrators elsewhere do not. Confirm the current cost-sharing structure with DHHS before describing it to a family, since the formula has been legislated and re-legislated.
And New Hampshire is a section 209(b) state, permitted to apply eligibility criteria more restrictive than the federal SSI standard in certain respects. The practical instruction for you is narrow: do not quote a resource limit from a national chart or from a colleague in another state. Direct the family to confirm current figures with DHHS, and confirm them yourself before putting anything in a handout. Our page on New Hampshire Medicaid asset and income limits covers the framework for families.
The hospital side is concentrated. Dartmouth Health, which took its current name in 2022, anchors the Upper Valley and much of the north; Catholic Medical Center and the Elliot Hospital system serve the Manchester area; and a network of smaller community and critical access hospitals covers the rest. Referral patterns among them are well established, which makes documented neutrality in your recommendations more important, not less.
Your obligations under 42 C.F.R. 482.43
The Medicare Conditions of Participation set the discharge planning requirement at 42 C.F.R. 482.43, substantially revised by the CMS discharge planning final rule effective in November 2019 implementing the IMPACT Act. Four elements shape how you handle money.
The hospital must operate a discharge planning process covering all inpatients and identifying those likely to suffer adverse health consequences without adequate planning. The plan must be developed with the patient and, where applicable, the patient’s representative or support person — collaboration is the requirement, not a signature at the end. Where post-acute care is indicated, the hospital must assist in selecting a post-acute provider by using and sharing data on applicable quality and resource use measures relevant to the patient’s goals of care and treatment preferences, and must document that the list was presented. And the hospital must not specify or otherwise limit the qualified providers available to the patient, while disclosing any home health agency or skilled nursing facility in which it holds a disclosable financial interest.
That final requirement is the principle everything else on this page rests on. The rule exists to keep the choice with the patient. Naming a single vendor — a facility, an agency, or a financial company — narrows the choice. Presenting the range and documenting the family’s selection preserves it. CMS enumerates post-acute providers because that is its jurisdiction, but a surveyor or a plaintiff’s attorney reading your notes will apply the same standard to a financial suggestion, and so should you.
The MOON and the three-midnight rule
Medicare Part A covers skilled nursing facility care only after a qualifying inpatient hospital stay of at least three consecutive days. The admission day counts; the discharge day does not. Observation time does not count at all, because observation is an outpatient service billed under Part B regardless of how many nights the patient spends in a hospital bed.
Families cannot see the distinction, which is why it produces more anger than anything else in discharge planning. Three nights classified as observation produce no SNF benefit, and the family finds out when the facility asks for a deposit.
The NOTICE Act, Public Law 114-42, created the Medicare Outpatient Observation Notice — the MOON, CMS form 10611 — specifically to force disclosure. A patient receiving observation services as an outpatient for more than 24 hours must receive the MOON no later than 36 hours after observation services begin, with an oral explanation and a signature acknowledging receipt. Delivering it on time is the compliance requirement; making sure the family understands it is the professional one. Say the sentence out loud in plain words: this stay may not qualify the patient for Medicare nursing home coverage.
There is also an appeals dimension that has developed out of federal litigation over beneficiaries reclassified from inpatient to observation status, with CMS implementing a process for those appeals. Confirm current procedures and deadlines with your organization’s compliance or revenue integrity function rather than relying on a summary, because the details have moved recently and they affect what a family can recover.
| Item | New Hampshire detail |
|---|---|
| Statute | RSA ch. 408-D, Life Settlements Act (Title XXXVII) |
| Definition of terminally ill | RSA 408-D:2 — death reasonably expected in 24 months or less |
| Required disclosures | RSA 408-D:9, provider and producer disclosures to the viator |
| Regulator | New Hampshire Insurance Department |
| Medicaid agency | DHHS, Bureau of Elderly and Adult Services |
| Home and community-based alternative | Choices for Independence waiver |
| Eligibility framework | 209(b) state — do not import national resource figures |
| State tax on settlement proceeds | None; I&D tax repealed after 12/31/2024, no estate or inheritance tax |
| Median semi-private nursing facility cost | Roughly $12,000–$13,500 per month in recent surveys |
Days 21 to 100, and the benefit-period reset
After a qualifying stay, Part A covers up to 100 days of skilled nursing care per benefit period. Days 1 through 20 carry no coinsurance; days 21 through 100 carry a daily coinsurance CMS resets annually, which stood at $209.50 per day in 2025. Use the current-year figure. A benefit period ends after 60 consecutive days with no inpatient hospital or skilled care, which is how a patient can earn a second 100-day allotment later in the same year.
The benefit-period reset is worth explaining, because families rarely understand it and it changes planning. A patient discharged home in March who stays out of inpatient and skilled care through May has begun a new benefit period by late May, and a June readmission with a qualifying stay opens a fresh 100 days. That is not a reason to delay care, but it is a reason to track dates rather than assume the benefit is exhausted.
The two standard corrections still apply. The 100 days is a maximum, and coverage stops when skilled need stops, which is often well before day 100. And the back eighty days cost roughly $16,800 at the 2025 rate — not nothing, and it lands before private pay even begins.
Day 101, or the day skilled coverage ends, is the cliff: private pay at the facility rate until Medicaid eligibility is established. That interval is where the asset decisions get made under pressure. Our page on nursing home Medicaid spend-down lays out the sequence for families.
The eligibility gap, and how families fill it
Federal rules at 42 C.F.R. 435.912 give the state generally 45 days to decide an application, or 90 days where a disability determination is required. Long-term care applications routinely exceed the standard because five years of financial records must be verified under the 60-month look-back at 42 U.S.C. 1396p(c). Federal law allows retroactive coverage for up to three months before the application month under 42 U.S.C. 1396a(a)(34); confirm how New Hampshire currently applies it with DHHS.
The rule that decides whether a life insurance policy is a problem is federal and worth memorizing. Under 20 C.F.R. 416.1230, the cash surrender value of life insurance is a countable resource unless the total face value of all policies on that insured is $1,500 or less, in which case the cash value is excluded outright. Above that face-value threshold, the entire cash value counts. Term insurance with no cash value is not a resource at all. Community spouse resource allowances follow an indexed federal minimum and maximum; the 2025 range ran from $31,584 to $157,920. Because New Hampshire is a 209(b) state, confirm the applicant resource figure with DHHS rather than importing one.
Then there is the distinction families reliably invert, and which you should hand off rather than resolve: a sale of a policy at fair market value is not an uncompensated transfer and creates no look-back penalty, but the cash proceeds become a countable resource in the month after receipt. Solving a premium problem in one month can defeat eligibility the next. That timing question belongs to an elder law attorney or Medicaid planner, not to you. See our New Hampshire Medicaid planner guide and our page on the Medicaid look-back and selling a policy.
One favorable New Hampshire fact for the family’s math: the state imposes no tax on wages or capital gains, and the Interest and Dividends Tax was repealed for taxable periods beginning after December 31, 2024. New Hampshire also has no estate or inheritance tax. So settlement proceeds carry no state tax cost and there is no state death tax argument for holding a policy the family cannot afford.
RSA 408-D and what a legitimate transaction looks like
The regulator is the New Hampshire Insurance Department, which maintains consumer material on viatical fraud, including the practice known as clean sheeting — concealing a known condition on an insurance application with the intent of later monetizing the policy. The governing statute is the Life Settlements Act at RSA chapter 408-D, in Title XXXVII of the Revised Statutes Annotated.
Two sections give you a usable checklist. RSA 408-D:2 carries the definitions, including terminally ill, defined as an illness or sickness that can reasonably be expected to result in death in 24 months or less. RSA 408-D:9 sets out the disclosures a life settlement provider must make to the viator and insured and a producer must make to the viator, including any affiliation between the provider and the issuer of the policy, the provider’s identity and contact information, and affiliations between the provider and any purchaser.
You are not enforcing that statute, but you can tell a family what a legitimate transaction looks like: written disclosures in hand before signing, a company that is licensed with the Insurance Department and whose license they verify themselves, no upfront fee for an evaluation, and no request for a Social Security number, bank information, or medical records before anyone has told them whether the policy is even worth pursuing. Those last two are the most reliable warning signs in this market. Our page on life settlement scams and red flags is written to be handed over, and life settlement licensing in New Hampshire covers verification.
Documentation that protects you, and the compensation rule
The practice that survives review is simple. Hand the family a written menu of funding options, unranked, with no company names. Include personal savings and family contribution; VA Aid and Attendance for a wartime veteran or surviving spouse; an existing long-term care insurance policy; a reverse mortgage on a home the patient will not return to; an accelerated death benefit or chronic illness rider that may already be attached to a life insurance policy at no additional cost; a loan against cash value; surrender; sale in the regulated secondary market; Choices for Independence as an alternative to facility placement; and Medicaid. Add ServiceLink, New Hampshire’s aging and disability resource network, as a neutral referral point.
Put the accelerated death benefit rider near the top. It is frequently already owned and already paid for, requires only a call to the carrier, and produces no commission for anyone, which is why families never hear about it from anyone selling something. See our page on accelerated death benefit riders.
Then write the note: funding options discussed, written list provided, no specific vendor recommended, family referred to their own advisers. That note is what a compliance reviewer looks for and it is also simply accurate.
On compensation the rule is absolute. Accept nothing — no referral fee, no gift card, no catered education from a single company, no honorarium. The federal Anti-Kickback Statute at 42 U.S.C. 1320a-7b(b) and the beneficiary inducement provision at 42 U.S.C. 1320a-7a(a)(5) are what counsel will analyze; your hospital’s conflict of interest policy, the freedom-of-choice requirement in 42 C.F.R. 482.43, and the professional codes governing social workers and nurses all reach the same answer without needing that analysis. Several states’ insurance codes go further and prohibit a settlement licensee from paying a finder’s fee to anyone providing medical services to the insured. Nothing on this page is medical, legal, tax, or financial advice or a recommendation about any patient’s care. Pine Lake Life Solutions provides education and a free policy review and does not purchase policies; the review is free at (305) 209-7183, a number for the family to call rather than for you to dial.
Frequently Asked Questions
Should I raise Choices for Independence before a nursing facility?
Include it on the written menu alongside facility placement rather than recommending either. New Hampshire’s home and community-based waiver is frequently a better clinical and financial fit for a patient who can be supported at home, and many families do not know it exists. Presenting it widens the choice without narrowing it, which is exactly what the discharge planning rule contemplates.
Can I quote New Hampshire’s Medicaid asset limit from a national chart?
No. New Hampshire is one of the remaining section 209(b) states, permitted to apply eligibility criteria more restrictive than the federal SSI standard in certain respects, and national summaries publish a single nationwide figure that may not reflect New Hampshire’s methodology. Direct the family to DHHS for current figures and confirm anything you put into a department handout.
The patient will be home for a few months. Does the 100-day benefit reset?
A benefit period ends after 60 consecutive days with no inpatient hospital or skilled nursing care, and a new qualifying hospital stay after that opens a fresh 100 days. Track the dates rather than assuming the benefit is exhausted. This is one of the few pieces of Medicare arithmetic that works in a family’s favor and it is routinely missed.
What should a family check before signing with a settlement company?
That the provider and any broker are licensed with the New Hampshire Insurance Department and that they verified it themselves; that the written disclosures required under RSA 408-D:9 are physically in hand before signature; that no upfront evaluation fee is being charged; and that nobody asked for a Social Security number, bank details, or medical records before telling them whether the policy is worth pursuing.
Do settlement proceeds cost a New Hampshire family anything in state tax?
No. New Hampshire has never taxed wages or capital gains, and the Interest and Dividends Tax was repealed for taxable periods beginning after December 31, 2024. The state also imposes no estate or inheritance tax. Federal tax treatment still applies and is a question for the family’s accountant, but there is no New Hampshire layer on the proceeds.
How do I document a funding conversation so it holds up?
Note that funding options were discussed, that a written list of options was provided, that no specific vendor was recommended, and that the family was referred to their own attorney or accountant. Keep a copy of the handout in the department’s records. That combination shows you informed without steering, which is the standard the freedom-of-choice requirement is written around.
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Related Reading
- New Hampshire Medicaid Asset Income Limits
- Nursing Home Medicaid Spend Down
- Medicaid Planner Life Settlement Guide New Hampshire
- Medicaid Lookback Selling Policy
- Life Settlement Scams Red Flags
- Life Settlement Licensing New Hampshire
- What Is An Accelerated Death Benefit Rider
- Snf Business Office Life Settlement Guide New Hampshire
Pine Lake Life Solutions does not purchase life insurance policies and does not provide legal, tax, or investment advice. Information provided is for educational purposes only. Eligibility for any option, including life settlements, is not guaranteed and depends on individual circumstances, policy terms, underwriting, and market conditions. Consult independent legal, tax, or financial professionals before making decisions regarding a life insurance policy.