More on Medicare & Medicaid

CMS approves Nebraska Medicaid waiver with work requirements

Heritage Health Adult will create a two-tiered Medicaid system, with enhanced benefits for those who meet requirements.

Jeff Lagasse, Associate Editor

The Centers for Medicare and Medicaid Services has approved Nebraska's new Medicaid Section 1115 demonstration, "Heritage Health Adult," which will create a two-tiered Medicaid program in the state that will go into effect on April 1. The demonstration was effective on October 20.

Enrollees in the Medicaid expansion population will be eligible to receive benefits including dental, vision and over-the-counter drug coverage in exchange for completing engagement activities, such as working 80 hours per month.

That enhanced package will be known as "Prime" coverage. Those who don't meet the work requirements will be denied access to the additional benefits, instead receiving coverage under the state's "Basic" package.

Focus on Health Equity

Expanding access, ending disparities, empowering communities. See our coverage >>


The demonstration applies to adults who are not medically frail or pregnant of ages 21 through 64. They also should be eligible under the Medicaid adult group expansion, having income at or below 138% of the federal poverty level. Low-income adults who are 19 or 20 years old and/or those who are medically frail, children, pregnant, elderly adults and others eligible on the basis of a disability will not be affected by the demonstration and already have access to the additional benefits.

Nebraska's work requirements break from those implemented in other states, which simply tie Medicaid eligibility to a fixed amount of work or education hours per month. Other requirements for the additional benefits under Nebraska's two-tier plan include attending annual health visits, completing a health risk assessment, maintaining employer-sponsored coverage and not missing more than three scheduled appointments in a three-month window. 

In 2022 the requirements become steeper, with enrollees expected to participate in work, job-seeking activities or education for at least 80 hours per month.

Starting April 1, 2022, beneficiaries must also participate in community engagement activities and notify the state Medicaid agency in a timely manner of any changes that would affect eligibility for the additional benefits. Beneficiaries with circumstances limiting their ability to meet the community engagement requirement may request an exemption, and those who fail to meet one or more engagement requirements, including, but not limited to community engagement, may request a good-cause exception so that their access to the additional benefits under the demonstration will not be affected.


Work requirements have been controversial in other states. In February, for example, a federal appeals court ruled that the Trump Administration unlawfully allowed Arkansas to implement a work requirement on those covered under that state's Medicaid expansion program, echoing a lower court ruling from 2019.

Arkansas was the first state to create such a work requirement, tasking enrollees aged 19-49 with clocking 80 hours per month on work, volunteering or job hunting, which then had to be reported via Internet or phone. According to Arkansas Online, 18,164 people lost coverage during the nine months the requirement was in effect, and were barred from re-enrolling for the remainder of the year.

CMS' announcement of Nebraska's work requirements drew pushback from Nebraska Appleseed, a nonprofit focused on, in part, promoting access to affordable healthcare. It called the Heritage Health Adult waiver "unnecessary" and "a step in the wrong direction."

"By the Department of Health and Human Services' own estimates, the waiver will result in tens of thousands of people being locked out of dental, vision, and over the counter drug benefits," the group wrote on its website. "The waiver does not 'enhance' benefits; it is indeed designed to deprive enrollees of those benefits.

"Nebraska does not need a complicated waiver system that makes it harder for people to access the care that they need."


"Governor Ricketts and his team deserve credit for responding to President Trump's invitation to design innovative state-led solutions that promote health and well-being among Medicaid beneficiaries," said CMS Administrator Seema Verma. "The Nebraska demonstration is a unique model designed to provide a voluntary pathway to added benefits for certain adult beneficiaries who participate in wellness activities, as well as work and take part in other community engagement activities, which can help lift them from poverty and put them on a road to improved health and independence."

Twitter: @JELagasse
Email the writer: