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How Nebraska’s rules work
The requirement applies to adults ages 19 to 64 covered through Medicaid expansion, about 70,000 people in Nebraska. They must work or volunteer at least 80 hours a month, attend school at least half-time or join job training. Earning at least $580 a month, the minimum-wage value of 80 hours, also counts. Exemptions cover caregivers of young children or disabled parents, people in addiction treatment and those deemed medically frail; the state published a 295-page list of qualifying conditions.
The state will check most enrollees against existing data, including claims and credit agency data. Between 20,000 and 28,000 people, plus several thousand new applicants a month, will need to supply more information and will have 30 days to respond. Eligibility reviews move from annual to every six months. Nebraska is accepting self-attestation for some categories and is not adding staff to run the program.
Why hospitals are concerned
History suggests paperwork, not unwillingness to work, drives most coverage losses. In Arkansas’s 2018 program, more than 18,000 people lost coverage in nine months. The Nebraska Hospital Association has raised concerns about more uninsured patients, and the federal law also cuts retroactive eligibility for expansion enrollees from three months to one, so hospitals have less room to secure coverage after an emergency admission.
Nationally, the requirement reaches expansion states starting in 2027. The Congressional Budget Office projects 4.8 million more uninsured people over a decade from this provision. A Commonwealth Fund analysis cited by Becker’s estimated that hospital operating margins in expansion states could fall by up to 13.3%. CMS rules on documentation are expected this summer, and the administrator has signaled skepticism of self-attestation, so Nebraska’s approach may change.
What to do before your state goes live
- Model the exposure. Estimate how many expansion patients you see, their likely exemption status and the revenue at risk from a 10% to 20% disenrollment rate.
- Strengthen front-end eligibility. With only one month of retroactive coverage, financial counselors need to screen and enroll at registration.
- Help patients document exemptions. Clinicians can identify medically frail patients early, and clinics can help with forms.
- Work with your state. Data-matching rules and notice timing will shape how many eligible people fall off.
Archive entry for May 3, 2026, added Nov. 11, 2026.