Early Data on Nebraska Medicaid Work Requirements and Coverage Outcomes

On May 1, 2026, Nebraska became the first state to enforce new Medicaid work requirements, conditioning eligibility for adults in the Affordable Care Act expansion group and certain waiver programs on meeting specific employment, income, or educational benchmarks. A KFF analysis shows that 46 percent of new applicants and 34 percent of individuals renewing coverage met qualifying activities between May and August 2026, while 14 percent of new applicants and 7 percent of renewing enrollees had applications denied or lost coverage due to not meeting the standards.

Nebraska Implementation and Federal 1115 Waiver Timeline

The implementation stems from a 2025 federal reconciliation law requiring states to condition Medicaid eligibility on work requirements starting January 1, 2027. Nebraska exercised its option to enforce the rules ahead of that national deadline. KFF data indicate that while most Medicaid adults under age 65 are already working or face barriers to employment, the early rollout in Nebraska provides the first empirical look at how these eligibility checks function in practice.

Data presented at Nebraska’s September Medicaid Advisory Committee meeting outlined application outcomes processed between May and August 2026. Out of 9,614 applications processed during that window, some were submitted prior to May and exempt from the rules, while 4,434 were denied for reasons unrelated to work requirements, such as household income exceeding eligibility limits. Among applicants actually subject to the rules, 86 percent met qualifying activities, qualified for an exclusion, or secured a short-term hardship exception, leaving 14 percent facing denials.

Qualifying Activities and Mandatory Exclusions

To maintain Medicaid coverage under the new rules, adults must satisfy either a qualifying activity or an approved exclusion category. Qualifying activities include working at least 80 hours a month, maintaining a monthly household income of at least $580, or attending school at least half-time. Seasonal workers can qualify by averaging the minimum wage multiplied by 80 hours over a six-month period, while others may fulfill the requirement through volunteering, participation in a work program, or a combination of approved activities.

State rules require officials to evaluate whether an individual qualifies for an exclusion before assessing work hours. Approved exclusions cover pregnant and postpartum individuals, American Indian and Alaska Natives, parents and caretakers of dependent children under age 14 or disabled individuals, disabled veterans, incarcerated individuals, individuals receiving SNAP benefits who are not exempt from SNAP work requirements, and people classified as medically frail. Data from the September Medicaid Advisory Committee meeting show that 39 percent of new applicants and 57 percent of individuals renewing coverage qualified for an exclusion.

Verification Methods and Hardship Exceptions

Nebraska relies on automated state data and self-declaration forms to verify compliance. When the state can automatically verify that an enrollee meets work requirements, it issues an approval notice. If data is insufficient, enrollees receive a notice and a declaration form that must be completed and returned within 30 days. Under interim federal rules, states may accept self-declaration through 2027, but beginning in January 2028, documentation must be requested from individuals when state data files are lacking, except for medical frailty exemptions.

The state has also established optional short-term hardship exceptions for enrollees facing extenuating circumstances. These exceptions cover residents in counties with high unemployment rates, individuals affected by natural disasters, patients admitted to a hospital or nursing facility, and people who must travel outside their community for extended medical care. Despite these provisions, data show that only a small fraction of individuals—2 percent of new applicants and 2 percent of renewals—utilized short-term hardship exceptions.

Broader Policy Implications and Rural Healthcare Access

The early data from Nebraska highlights ongoing tensions between welfare reform initiatives and healthcare equity, particularly in rural and underserved areas. The rollout exposed significant barriers for low-income adults with disabilities, caregiving duties, or unstable employment who struggled to document their status. Dr. Elena Torres, a health policy analyst at the Center for American Progress, noted that imposing work requirements without robust infrastructure for job readiness, childcare, and transportation disproportionately penalizes vulnerable populations.

Legal and policy analysts, including those tracking the Medicaid 1115 waiver program through the National Health Law Program and the Urban Institute, point out that similar work requirement policies historically correlate with drops in enrollment and increased gaps in preventive care. With additional states moving to implement similar rules under federal waiver frameworks, public health advocates continue to monitor Nebraska’s outcomes to assess the long-term impact on coverage and health service utilization.