In May, Nebraska will be the first state in the nation rolling out new Medicaid work requirements under President Donald Trump’s tax law.

With less than a month to go, providers and advocates in the state say they’re worried about still-unresolved specifics about eligibility and public outreach, and the impact on their patient base.

“There is still a lot of uncertainty, and that, compounded by a rushed timeline, gives a lot of concern to our hospital leaders and our membership,” said Jeremy Nordquist, CEO of the Nebraska Hospital Association.

Related: How Nebraska’s Medicaid work rules may strain health centers

Nebraska offers a preview of what providers, insurers and residents around the country may face as other states move to hit the Jan. 1 Medicaid work requirement deadline set by the tax law.

“Others are going to look to you as an example,” Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz told Nebraska Gov. Jim Pillen (R) in a December news conference announcing the rollout timeline. “When you go first, it can be harder, but everyone behind you, they can draft off you and benefit from your from your work.”

National groups say they’re closely watching how Nebraska ultimately handles exemptions and outreach.

“We were asking the same questions,” said Sophia Tripoli, senior director of health policy at health coverage advocacy organization Families USA.

Under the July law, everyone of working age who gets Medicaid under the expansion of eligibility through the Affordable Care Act of 2010 must work, volunteer or go to school for 80 hours a month if they don’t meet certain exemptions.

Nebraska has some 70,000 people in the expansion population. A March analysis from the left-leaning think tank Urban Institute estimated if the state works hard to keep people on the rolls, about 16,000, or 22%, will lose coverage. The number could be as high as 30,000 if the state doesn’t take strong steps.

The state has said it expects to verify Medicaid eligibility of 60% to 72% of the affected people with its own records. The rest will have to undertake a verification compliance process. The Nebraska Department of Health and Human Services did not respond to requests for comment.

Nordquist warned even small coverage losses can be damaging.

“Around 30% of our hospitals are still struggling to run a sustainable margin,” he said. “We’re just not at a point where we can absorb a lot of additional losses.”

Who is exempt?

One major issue, providers say, is ongoing confusion about the exemptions to the requirements, which are not defined in federal statute and likely to vary considerably from state to state.

The law states beneficiaries are exempt if they care for a child under 14 or a disabled person, are disabled themselves or are medically frail. People suffering temporary hardships are also excluded.

In a March town hall, DHHS spokesperson Collin Spilinek noted information about the definitions of exemptions was “subject to change.” The session was the most recent in a series attended by about 200 industry stakeholders to get the word out about the upcoming requirements.

As of April, Nebraska state lawmakers are still seeking to define some of the exceptions, such as what specifically counts as a temporary hardship. CMS has been working with the state on specifics, but the agency is not expected to release formal guidance until June.

How providers may be tapped to validate medical frailty isn’t clear. They also don’t know what staffing they may need to help patients determine if they are exempt and to ensure their Medicaid coverage is still in place, Nordquist said.

“We carry a pretty heavy burden on that already,” Nordquist said.

What’s the best way to alert affected individuals?

The state has been sending letters, texts and emails to affected beneficiaries. It has also posted extensive information and FAQs online.

But Sarah Maresh, the healthcare access program director at nonprofit social justice organization Nebraska Appleseed, said her group has been hearing from people who don’t know if they are covered under the Medicaid expansion and therefore subject to the work requirements.

If individuals don’t know they are in the expansion population, they may fail to complete necessary verifications and lose their coverage.

Nebraska Appleseed is ramping up outreach to those affected by the requirements, Maresh said, as is the Nebraska Health Association.

Cindy Jordan, the CEO of Pyx Health, which works with insurers and others trying to make sure enrollees understand and respond to opportunities for care, said outreach is particularly hard in the state’s many rural areas.

Her company typically achieves response rates of around 8% using texts, email and snail mail, which she described as the “omni-channel” approach used by much of the healthcare world.

Her firm, which is working on behalf of one insurer that enrolls Medicare and Medicaid beneficiaries in Nebraska, found outreach needs to be more creative and personal, she said. They send non-responsive enrollees a box of food and a promise of more in return for responses. That gets answer rates up over 30%, Jordan said.

“When we build that trust, we’re able to help folks,“ Jordan said.

Key Takeaways

• Nebraska will launch its Medicaid work requirements on May 1, making it the first state to implement restrictions in President Trump's 2025 tax-cut law.
• The state has been working with CMS and local stakeholders to get up and running, but providers and advocates still have questions.
• National groups say they’re closely watching how Nebraska ultimately handles exemptions and outreach.

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