New Hampshire's DD Billing Reset: What Direct Bill and Conflict-Free Case Management Mean for Providers

New Hampshire's developmental disabilities service system went through one of its most significant structural changes in years when direct billing and conflict-free case management requirements took effect July 1, 2023. The ripple effects are still being felt — and a 2026 waiver renewal is adding another layer of change.

The Direct Billing Shift

Prior to July 1, 2023, New Hampshire's DD, Acquired Brain Disorder, and In-Home Supports Waiver services were primarily administered through Area Agencies, which served as both service coordinators and billing entities. Under the federal HCBS Final Rule, this created a conflict-of-interest problem: the same entity that managed a person's care plan was also billing for services.

CMS had placed New Hampshire under a Corrective Action Plan requiring the state to separate case management from direct service provision and implement direct billing from individual providers. After multiple extensions — the compliance deadline was pushed from August 2021 to July 2023 — the transition went live.

For providers, this wasn't just a compliance change. It was a billing system overhaul. Agencies that had never billed Medicaid directly suddenly needed to enroll through NH's MMIS Health Enterprise Portal, set up NH Easy accounts, obtain Medicaid Billing IDs, and submit claims on the CMS 1500 form to DHHS rather than routing through an Area Agency. The NH Easy BDS Service Provider Management platform launched July 1, 2024, adding another operational requirement: all providers needed registered NH Easy administrators for their organization.

The Rate Problem Underneath It All

Compounding the billing transition is a rate structure that BDS itself has acknowledged is outdated. NH's DD service rates were developed in 2007. Nearly two decades of workforce cost increases, service redefinitions, and inflation have created a widening gap between what providers are reimbursed and what services actually cost. BDS has publicly stated that the outdated rate system has led to challenges for providers in ensuring they're reimbursed for the true cost of services — and has contributed to inequitable access across the state.

A rate reform process is underway, rooted in the same CAP requirements that drove the direct billing changes. But until new rates are fully implemented, providers are navigating a billing environment where the systems are new but the reimbursement is built on 2007 assumptions.

The EVV Layer

On top of the billing transition, NH Medicaid has been rolling out EVV under an open model with AuthentiCare (First Data) as the state aggregator. January 2025 provider meeting notes reveal ongoing implementation friction — IVR issues, MCO billing form requirements shifting from UB-04 to CMS 1500, and persistent questions about which visit types require EVV versus which can be billed directly to the payer.

NH providers managing EVV compliance alongside direct billing implementation are running two parallel operational workstreams that interact at the claim level. A visit captured in AuthentiCare needs to match against a claim submitted through the correct channel — DHHS for FFS, or directly to the MCO for managed care members — on the CMS 1500 form. Mismatches at any point in that chain create denials.

The 2026 Waiver Renewal

DHHS launched the public comment process for the DD Waiver and ABD Waiver renewal covering 2026–2031 in late December 2025, with sessions running through early 2026. The renewal represents an opportunity for BDS to update service definitions, address rate methodology, and align the waiver structure with the direct billing and CFCM changes that have been implemented. For providers, it's also a signal that the regulatory environment will continue evolving — and that service definitions, authorization structures, and billing codes may change again once the renewal is approved.

The providers best positioned for the 2026 renewal and beyond are the ones who have fully stabilized their direct billing workflows now — with clean EVV records, correct billing forms, and NH Easy fully operational — rather than still catching up to the 2023 transition.