Payers, Policy

Nebraska gets approval to add work requirements to Medicaid expansion

After Nebraskans cast their vote for Medicaid expansion in 2018, the state is finally expanding coverage to more residents. As part of the state’s rollout, it split its expanded Medicaid plans into two tiers, with work and other requirements to access dental and vision coverage.


Nebraska is the latest state to add work requirements to its Medicaid expansion, but it’s taking a slightly different approach. Instead of hinging Medicaid coverage on work requirements, the state divided its Medicaid plans into two tiers, with newly-eligible adults tasked with meeting a list of requirements to get dental, vision and over-the-counter drug coverage.

But many of the state’s residents, who voted for Medicaid expansion back in 2018, feel like the new tiered system flies in the face of their decision, according to more than 40 pages of comments on the Medicaid waiver.

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“The proposal put forward by Nebraska subverts the intent of the voters, one by delaying expansion and two by limiting coverage available,” one commenter wrote in January. “Please reject this proposal and require Nebraska to implement expansion immediately and as intended.”

Several also expressed concerns that the complex reporting requirements could limit beneficiaries’ access to healthcare and add to the administrative burden for medical practices.

The Centers for Medicare and Medicaid Services approved the Section 1115 waiver on Tuesday. It will go into effect after April of next year.

Earlier this summer, Nebraskans who made below 138% of the federal poverty level — about $17,609 for a single person or $13,156 for a family of four — were able to enroll in Medicaid. Before the pandemic, Nebraska estimated 90,000 adults would gain coverage.

They would be enrolled in the basic version of the plan, unless they are pregnant, between the ages of 19 and 20, or medically frail.  Otherwise, newly eligible adults would have to meet a litany of requirements to get coverage for dental, vision and over-the-counter medications, including:

  • Meeting certain wellness initiatives, such as attending an annual health visit and completing a health risk assessment
  • Maintaining employer-sponsored coverage, if available, and not missing three or more scheduled appointments over a six-month period.
  • And on top of that, starting in 2022, Medicaid enrollees must participate in “community engagement activities” of at least 80 hours per month, including work, job-seeking activities, or enrollment in an accredited college or post-secondary training program, or volunteering with a public charity.

Nebraska expects between 41,000 and 51,000 people would qualify for this this “demonstration program.” Medicaid coverage for the non-expansion group would still cover dental and vision services.

Since CMS Administrator Seema Verma indicated the administration’s support of work requirements, several states have tried to implement their own versions of the policy, but they were overturned due to legal challenges. In February, a federal appeals court struck down Arkansas’ Medicaid work requirements, after a previous judge ruled that they were “arbitrary and capricious.” The policy, which went into effect in 2018, required adults covered by the state’s Medicaid expansion to work at least 80 hours per month. An estimated 18,000 people lost their coverage as a result.

Photo: zimmytws, Getty Images