Starting in 2019, people getting health insurance through New Hampshire’s Medicaid expansion program will have to comply with a new work and “community engagement” requirement in order to continue receiving coverage.

The Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicaid programs across the country, formally approved New Hampshire’s request to add the requirements on Monday.

(Read CMS's letter approving New Hampshire's work requirements here.)

New Hampshire’s plan would require people to log at least 100 hours a month at work, school, job training, community service or other “community engagement” activities. There are exemptions for caregivers, people with disabilities and parents with kids under age 6, among other circumstances.

Some have expressed concern that the new eligibility rules will be difficult for people to comply with and will ultimately make it harder for people to get needed health coverage.

In her letter approving New Hampshire's work requirements, CMS Administrator Seema Varma acknowledged these concerns but said the state's plan seems to provide enough flexibility to make sure people with disabilities or other vulnerable populations aren't shut out of coverage.

Varma noted that "New Hampshire will be exempting from the requirement those individuals who are medically frail, as well as those individuals whom a licensed provider has documented to be temporarily unable to participate in community engagement activities due to illness or incapacity."

With its new federal approval, New Hampshire is poised to become the fourth state to add work requirements to its Medicaid program.

New Hampshire and other states have tried to add work requirements to their Medicaid programs in the past, but the Obama administration blocked all of those applications. Under the Trump administration, however, the federal government has been more open to the idea.

Since January, CMS has greenlit work requirements for Medicaid in Kentucky, Indiana and Arkansas. At least six other states are still waiting for approval, according to the Kaiser Family Foundation.

The news about New Hampshire’s work requirements comes several days after the Republican-controlled New Hampshire House of Representatives voted to renew Medicaid expansion for at least two-and-a-half — and potentially as many as five — more years.

While past efforts to renew the program ran up against skepticism from many House Republicans, the state’s move to tighten eligibility standards for the program helped to win over support from more of them this time around.