Nebraska is set to become the first state to enforce Medicaid work, volunteer or education requirements for new applicants on Friday, months before a federally required start date. The state’s move comes as advocates and health-policy experts warn that a fast rollout may leave implementation questions unresolved and could disrupt coverage for people who would otherwise remain eligible.
Supporters of the approach say it is intended to expand participation in work and community life among able-bodied adults. Nebraska Republican Gov. Jim Pillen said in December that the state would implement the requirement eight months early, and he framed the goal as “making sure we get every able-bodied Nebraskan to be a part of our community,” according to the policy description.
Under the policy, the requirement applies to people in Medicaid expansion coverage, not all Medicaid beneficiaries nationwide. For many Medicaid participants ages 19 through 64, the state will require proof that they work or do community service at least 80 hours a month, or that they are enrolled in school at least half-time.
The state also plans to change the cadence of eligibility checks. Nebraska will review eligibility every six months rather than annually, and advocates say that faster rechecks can increase the likelihood that people lose coverage if their circumstances change. Exceptions will apply for some groups, including people considered too medically frail to work and those in addiction treatment programs, among others.
Policy groups say those exceptions and compliance rules raise practical concerns, particularly as states prepare for federal guidance expected in June. Health Center Association of Nebraska CEO Amy Behnke said staff members helping people enroll with Medicaid and her clients have many questions, including whether apprenticeship programs count for the requirement only if participants are certified by the state’s labor department and how far someone would need to travel to a hospital to qualify for a care-related exemption.
Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said the rapid state rollout can serve as a test case. “It can be used as a lesson for other states, both where things go well and where things don’t go well,” Tolbert said. Tolbert also said she did not know whether Nebraska’s detailed list of conditions that could qualify someone as medically frail is comprehensive, noting the state issued a 295-page list last week.
Urban Institute researchers have also flagged the role administrative systems play in enforcement. Michael Karpman, who researches health policy at the Urban Institute, said, “The higher the administrative burden, the more likely people are found noncompliant and disenrolled.” A March Urban Institute report estimated that nationally the changes would mean about 5 million to 10 million fewer people enrolled in Medicaid than otherwise.
Nebraska says it will first use data matching to check whether people are working or exempt, using information it says it already has for most of the roughly 70,000 people enrolled through the expansion. That process would leave between 20,000 and 28,000 people who would have to provide more information, plus an average of 3,000 to 4,000 new enrollees each month, based on the state’s planning described in the reporting.
At first, Nebraska plans to require proof that participants met the requirements in one month of the previous 12 months, with that window shifting to six months in 2027. Officials also described flexibility in how people can demonstrate compliance, including allowing records showing earnings at least $580, the amount someone earning minimum wage would make in 80 hours.
For people who do not submit requested information, Nebraska said applications could be denied or people who already have coverage could lose it after a 30-day window. For Bridgette Annable, a 21-year-old mother in southwest Nebraska, that timeline is already raising concerns about day-to-day stability. Annable said she received a letter warning she must meet the work requirement to keep benefits that pay for her insulin and diabetic supplies, and she said she is working part-time at 30 to 25 hours a week while calling out often due to fibromyalgia pain and bipolar episodes that leave her too tired to leave the house.
As Nebraska begins enforcement, other states and federal officials will be watching the administrative mechanics—what data the state can match automatically, which exemptions prove workable, and how quickly rules change as guidance arrives. The policy is part of a broader tax and policy law that President Donald Trump signed last year, and the federal requirements are not expected to start until later, leaving Nebraska’s early start as a preview of how the model may play out.
Mulvihill reported from Haddonfield, New Jersey.