Medicaid Expansion: Proposed changes would delay and complicate expansion

There have been a lot of developments in the last few weeks around Medicaid expansion in Nebraska. The Nebraska Department of Health and Human Services has announced a series of choices they made that will delay Medicaid expansion’s rollout until 2020, implement a series of complex and costly work requirements, and reduce coverage options for current Medicaid enrollees.

On April 1, the Nebraska Department of Health and Human Services (DHHS) filed the necessary state plan amendments (SPAs) to expand Medicaid in our state. These filings set the foundation for Medicaid expansion but also included a coverage start date of October 1, 2020. This coverage start date is around 23 months after voters passed Initiative 427. Nebraska voters passing Initiative 427 demonstrated an understanding of the health and financial challenges that result from not having insurance. However, under the DHHS plan for implementation, Nebraskans in the coverage gap continue to wait for coverage.

Along with the SPAs, DHHS also released a concept paper for a Section 1115 waiver project. A Section 1115 waiver is a demonstration project to deliver Medicaid in a way that is different from how Medicaid normally operates. Because it is a plan that deviates from traditional Medicaid law, it requires negotiation with and approval from the federal government. A Section 1115 waiver also requires public hearings and a notice and comment period and can take several months to be approved by the federal government.

Nebraska DHHS’s proposed Section 1115 waiver includes many elements. Specifically, the proposal would create the Heritage Health Adult Program, which would cover both adults eligible for Medicaid expansion and around 25,000 adults currently enrolled in Medicaid as parents or caretaker relatives. The Heritage Health Adult Plan would include a tiered benefits system with two levels of coverage called Basic and Prime.

  • Basic Coverage would include the Medicaid benefits package minus dental, vision, and over the counter drugs.
  • Prime Coverage would include dental, vision, and over the counter drugs.

To get Prime Coverage, Medicaid enrollees would have to engage in wellness requirements including choosing a primary care provider and completing an annual check up and, during the second year of the program, complete work requirements for 80 hours/month. The work requirements could be met through employment, participation in job search activities through the State of Nebraska, post-secondary education or apprenticeship, or volunteering through a public charity.

Adults currently eligible for Medicaid (those who aren’t becoming eligible through expansion) will be eligible for Prime Coverage during their first enrollment period (first six month of coverage). However, if Medicaid enrollees do not meet the requirements for Prime Coverage during their first enrollment period, they would receive Basic coverage for the next enrollment period. This means that the 25,000 adults currently enrolled in Medicaid could receive fewer benefits than they do now as a result of these program changes.

The proposed waiver would also modify a number of other areas of Nebraska’s Medicaid program:

  • Redeterminations: Currently, Medicaid enrollees must re-verify their eligibility annually. The proposal would require eligibility redeterminations every six months.
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT): Medicaid provides a more robust benefits package for children through age 21. EPSDT is a comprehensive set of diagnostic, treatment, and preventive services currently provided to individuals up to age 21. As part of the waiver, DHHS is requesting to only provide that coverage up to age 19.
  • Retroactivity: Currently, Medicaid eligibility is retroactive for up to three months prior to the date an individual enrolls in Medicaid if the individual would have been eligible for Medicaid during that period had they applied. DHHS is proposing to limit retroactive coverage to go back only to the first day of the application month for most groups enrolled in Medicaid, except pregnant women, children under 1 year old, and individuals in nursing facilities. Changes to retroactive coverage can have a significant negative financial impact on patients and providers.

This waiver proposal is complicated. It’s important to note that these proposed changes that reduce coverage, add needless complexity, and increase administrative costs were not contemplated or required by the ballot initiative passed by voters in November 2018. This waiver project is a choice; it is not something that we as a state must do to expand Medicaid. The SPAs filed on April 1 create the foundation for Medicaid expansion in Nebraska and are the only steps required by the initiative to expand Medicaid.


In coming months, your voice will be needed

to make sure Medicaid expansion is implemented as voters intended.


Call your state senator and urge them to tell DHHS to implement Medicaid expansion quickly and without work requirements and benefits changes voters did not authorize.

If you are personally affected by these proposed changes or waiting for Medicaid expansion and would like to take action, we would love to hear from you at or 402-249-2492.

Stay up to date with Medicaid expansion news

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