Tens of thousands could lose Medicaid coverage as Nebraska becomes first state to implement GOP work requirement

By Tami Luhby, CNN

(CNN) — Nebraska is launching work requirements in Medicaid on Friday, becoming the first state to implement a key pillar of the Republicans’ “big, beautiful bill.”

GOP Gov. Jim Pillen has said the mandate will promote long term independence. But community advocates and experts fear that tens of thousands of eligible low-income adults could lose their coverage due to paperwork burdens and other hurdles. They also criticize the state for enacting the requirement eight months before the deadline set by the law, failing to provide enrollees enough notice or information and opting not to hire more staff to oversee the new mandate.

Roughly 70,000 Nebraskans are covered through Medicaid expansion, which voters approved at the ballot box in 2018. But enrollment could decline by between 16,000 and 30,000 people in 2028 due to the work requirement, as well as a new federal provision that states must redetermine expansion enrollees’ eligibility every six months instead of every year, according to an analysis by the left-leaning Urban Institute.

The One Big Beautiful Bill Act, which President Donald Trump signed into law last July, enacted the first-ever federal work requirement in Medicaid, fulfilling a longtime Republican goal. It mandates that adults ages 19 through 64 who sign up for or are covered by Medicaid expansion work, volunteer, attend school or participate in a work program at least 80 hours a month. Among those who are exempt are pregnant women, parents of children under age 14, medically frail individuals and those in substance use disorder treatment programs.

The provision applies to 42 states that have fully or partially expanded Medicaid coverage to more low-income adults, as well as to the District of Columbia. In total, enrollment will decline between 3 million and 7 million people in 2028, the Urban Institute projects.

In Nebraska, those signing up for coverage through Medicaid expansion will have to show they meet the requirement in the month before they apply or that they qualify for an exemption. For existing enrollees, the state will start checking work requirements when they renew their coverage, starting July 31. They must meet the work mandate or qualify for an exemption for one month since their last renewal.

Nebraska will use various data sources to determine whether some enrollees are already working enough hours or qualify for an exemption. They can also meet the mandate if they earn at least $580 a month, which is equal to working 80 hours at the federal minimum wage.

But other participants will have to provide more information about their employment or attest that they are volunteering, enrolled in school or a work program, are medically frail or meet certain other exemptions. The declaration form asks for contact information for volunteer organizations, work programs and doctors, among others.

“For some people, there is going to be a significant documentation hurdle,” said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured. “That could mean those individuals, even though they are meeting the requirements, are simply not able to enroll because they can’t provide the documentation, or if they are enrolled, could still lose coverage because of the inability to provide the documentation.”

Enrollees are incredibly confused about the work requirement, said Sarah Maresh, health care access program director at Nebraska Appleseed, an advocacy group. Many don’t know whether the new mandate applies to them or whether they qualify for exemptions like being medically frail. The state is not doing enough outreach, she said, and the notices it has sent are vague and difficult to understand.

“This rush job will lead to a lot of harm,” Maresh said.

Hospitals and healthcare providers are also concerned that the “sudden implementation” could result in many patients losing coverage and suffering disruptions in care, especially in rural areas, the Nebraska Hospital Association said in a release in mid-April. The providers are bracing for potential financial losses and increases in administrative burdens.

The state Department of Health and Human Services, which oversees Medicaid, said it has increased its outreach efforts and is notifying enrollees by sending tens of thousands of mail, email and text messages. It also hopes to raise awareness through television, radio and social media campaigns.

“Our top priority is making sure members clearly understand changes to the program and how to maintain their coverage, which is why DHHS is committed to communicating and providing support every step of the way,” Drew Gonshorowski, director of the Division of Medicaid and Long-Term Care, said in a press release in early April.

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