Nebraska’s Rushed Implementation of Medicaid Work Reporting Requirements Puts Residents’ Health at Risk

On Friday, May 1, Nebraska will become the first state to subject Medicaid enrollees to work reporting requirements - eight months before states are required to do so under the Republicans' 2025 big budget bill (H.R. 1).

Work reporting requirements are a "solution in search of a problem", as we've previously explained, since more than 90% of adults on Medicaid are already working or would meet an exemption. Prior states' efforts to implement similar work reporting requirements resulted in widespread coverage losses and increased financial burdens on states and providers, all while employment rates remained stagnant. Nebraska's decision to rush these requirements further puts its residents' health at risk.

Under H.R. 1, beginning in 2027, all states must require adults enrolled in the ACA's Medicaid expansion to either demonstrate they are engaged in at least 80 hours per month of work or other community engagement activities, or document they meet one of several exemptions under the law - such as having a serious medical condition or being a full-time caregiver.

In Nebraska, these requirements will apply to over 70,000 low-income people, and the vast majority of these folks are already working or would meet various community engagement requirements or exemptions. Researchers estimate that between 28,000 and 41,000 Nebraskans will lose coverage when the requirements are put into place - and even those who are clearly eligible are worried they will be unfairly denied coverage.

Schmeeka Simpson lives in Omaha, NE and Medicaid provides health coverage to she and her three children.

"Medicaid has been instrumental in making sure that the prescriptions were filled and that the resources I needed to keep my children healthy and happy as much as possible were available," said Simpson.

Today, she juggles three and sometimes more jobs to provide for her family, and keeping up with bureaucratic paperwork to continuously document those jobs in order to keep her health insurance will add additional stress and burden for her. The thought of losing her Medicaid coverage, for herself or her children, is terrifying.

Speaking to KLKN news in March Schmeeka said, "Adding more requirements is going to guarantee that more people are denied. More people are going to be denied the health care that they need to be productive citizens. I feel that we should be making pathways easier for people to be healthy in Nebraska."

There are dangerous implications of Nebraska's rushed implementation, all of which demonstrate the state is ill-prepared to embark on work requirements:

• Rushed implementation means Nebraska cannot fully design and test new systems to assure their success. After H.R. 1, states have an incredibly compressed timeline to upgrade information technology (IT) systems, streamline data sharing across agencies, coordinate with Medicaid managed care plans, build robust monitoring and appeals mechanisms, train staff, and educate consumers. By some estimates, states will need at least 18 to 24 months just to set up the necessary IT systems, followed by at least four months of testing to ensure they work. Nebraska's health agency has not hired any new staff support and has allowed itself just a few months to accomplish this enormous task and is doing so without the benefit of comprehensive guidance from the Trump administration that would instruct them on how to configure their systems properly to meet federal guidelines.
• Inadequate outreach and education leave consumers with many unanswered questions. Starting in December, Nebraska's Health Department sent letters to every resident subject to the new requirements to inform them of coming eligibility changes. Although letters were sent to approximately 70,000 affected residents, roughly half did not receive a text message and fewer than 15% received an email, which are considered crucial methods for reaching a population that often moves or lacks stable internet access.

Even if impacted residents are aware of requirements, consumer-facing information provided by Nebraska lacks necessary detail about how to comply with work reporting requirements. The state provides only vague information about how it will verify data through automated (ex parte) methods, incomplete descriptions on important exemptions, and limited information on how applicants can self-attest for those exemptions. By rushing the process, Nebraska has made only cursory information available, leaving consumers without the information they may need to comply and providers and patient advocates without the tools they need to support impacted communities in meeting requirements.

• Enforcing disenrollment policies straight away needlessly kicks people off coverage. One approach to early implementation is to do a "soft-launch" where the system is up and running for a period of time before the state will disenroll people who cannot prove their compliance. For example, Arkansas is planning to start their work requirement program in July 2026, but not disenroll any member failing to meet requirements until required to do so on January 1, 2027. This will allow policymakers in Arkansas time to inform beneficiaries of requirements, test-drive automated processes they intend to use to determine compliance and work out other systematic kinks before going fully live. Nebraska has not chosen this more moderate approach and enforcement penalties begin immediately.
• Inadequate staffing will cause administrative failures that result in eligible people unnecessarily losing health coverage. With consumers lacking details that would help them apply on their own, many more people will be turning to Nebraska's Health Department staff for assistance. However, Nebraska plans to implement work reporting requirements without hiring any additional staff, even as other states are hiring dozens if not hundreds of new employees to assist in navigating massive new eligibility and enrollment changes.

For example, Montana (a state that also has early implementation ambitions) has projected it will need at least 60 new staff to help vet eligibility and exemptions and support consumers in understanding eligibility changes when their program launches in July. Nebraska, meanwhile, already struggles to assist consumers, with high call center wait times and slow Medicaid application processing. Nebraska will need additional staff and resources to manage the substantial administrative complexities of work reporting requirements.

What Happens Next

With a launch date set for May 1, Nebraska is putting the health coverage of tens of thousands of its residents at risk months before it needs to do so.

Families USA, along with partners like Nebraska Appleseed and others, will be closely monitor Nebraska's implementation of these new bureaucratic requirements. As consumer advocates, we will do everything we can to make sure those eligible for Medicaid can retain their health coverage and get the care they need, while continuing to hold state and federal policymakers accountable for their decisions. We urge our Nebraska partners and partners across the country to press their state leaders to take a flexible approach to work reporting requirement implementation to ensure the health and safety of people with Medicaid coverage.