Nebraska is set to become the first state to require work, volunteering or education activities for new Medicaid applicants, beginning Friday, ahead of a federally required timeline for Medicaid work rules. Advocates and health policy experts say the state’s fast start risks leaving applicants without clear answers about details that can affect whether they stay enrolled.
The work requirement is part of a broader tax and policy law signed by President Donald Trump last year. Nebraska Republican Gov. Jim Pillen announced in December that the state would implement the requirement eight months before it was required under federal rules, saying the goal was “making sure we get every able-bodied Nebraskan to be a part of our community.”
Under the change, the federal policy does not apply to all Medicaid beneficiaries, but instead to those enrolled under Medicaid expansion, which most states chose to cover more low-income residents. For many Medicaid participants ages 19 through 64, the requirement will center on work or community service at least 80 hours a month, or school enrollment at least half-time, along with eligibility reviews every six months instead of annually.
Advocates say the shorter review cycle could lead to faster coverage loss if circumstances change or if paperwork is delayed. They also point to the challenge of administering exemptions, including for people who are too medically frail or are in addiction treatment programs, among others, and say the details will matter in practice. “The higher the administrative burden, the more likely people are found noncompliant and disenrolled,” Michael Karpman, a researcher at the Urban Institute, said.
Nebraska officials say the state plans to use data matching before requesting documentation from applicants. The state says it will first match enrollees with other data it has to determine whether participants are working or exempt, and that it has that information for most of the roughly 70,000 people enrolled in Medicaid through expansion. That leaves a smaller group—between 20,000 and 28,000—expected to provide additional information, plus an average of 3,000 to 4,000 new enrollees each month.
At the start, Nebraska plans to require applicants to show they met the requirements based on one month of the previous 12. Officials say the timeframe will shift to six months in 2027, and that there is some flexibility in how people prove compliance. For example, instead of demonstrating 80 hours of work in a month, someone could provide records showing they earned at least $580, the amount someone earning minimum wage would make in 80 hours. People who do not submit requested information within 30 days of being asked could see applications denied or coverage lost.
The state’s rollout is already prompting concern and confusion among people who receive letters about the work rules. Bridgette Annable, who lives in southwest Nebraska, said she received a letter saying she must meet the work requirements or lose benefits that pay for insulin and diabetic supplies. Annable said she has taken a part-time job, despite saying she was advised against it to protect her mental health, and she said she calls out of work often due to fibromyalgia pain and bipolar episodes.
Officials at health centers assisting enrollees also said they face unanswered questions as staff respond to letters and forms. Amy Behnke, CEO of the Health Center Association of Nebraska, said staff members helping people enroll with Medicaid and their clients have questions, including whether apprenticeship programs count and, if so, whether the counts apply only to programs certified by the state’s labor department. She also said there is not clarity on an exemption for people who travel to a hospital for care, including how far someone must travel.
Policy experts and advocates also say the state issued a long list of conditions that may qualify people as medically frail, but some uncertainties remain. Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said KFF “don’t know if it’s a comprehensive list,” after the state issued its 295-page list of medically frail conditions. She also suggested Nebraska’s approach could offer lessons for other states, both where things go well and where they do not.
National estimates of the likely impact vary, but one forecast used by advocates and experts suggests meaningful enrollment losses. An Urban Institute report from March estimated that the changes would mean about 5 million to 10 million fewer people nationally enrolled in Medicaid than would have been otherwise. Choices states make about implementation, including the administrative steps required and the way compliance is verified, are expected to be a major factor in how many people lose coverage.
Nebraska’s plans are also expected to be shaped by additional federal guidance expected in June. That guidance could lead the state to adjust how it applies exemptions, documents compliance and reviews eligibility moving forward.