September 22, 2026
Good afternoon,
Below and attached are three articles discussing Medicaid Work Requirements from several vantage points. The themes in the articles (namely confusion, concerns over provider viability, etc.) are consistent. That’s why the NYS Council has made an all out push to compel state leaders to significantly increase the currently available resources in the OMH Uncompensated and Indigent Care pools, for OASAS to either apply for its own pool or at the very least set aside dedicated funds to ensure continuity of care from financially stretched providers, and to reset reimbursement to providers to a quarterly payment rather than waiting a full year to award uncompensated / indigent care funds to eligible providers.
Here’s a little more detail based on our recent conversations with state reps:
As to who will be exempt, who may be exempt, and who is not exempt from Medicaid Work Requirements, DoH will release a list of Codes corresponding to medical frailty. The state is establishing an internal multi-agency workgroup that continuously reviews and updates the code lists as needed. We did not receive a fixed date for the release of the Codes.
When we asked state representatives how to identify the ‘Medicaid Expansion’ population, we were told that the state’s assistor network and health plans will have this information and will work with providers. We disagree with this being the only approach to identifying this population because many of our member agencies do not employ assistors or navigators, health plans have no track record of cooperating when sharing information/data and it is an extra step providers should not have to take to obtain this information. Furthermore, the state has not required plans to be forthcoming with similar information in the past. We strongly encouraged our state colleagues to hold a Mental Health (MH) and Substance Use Disorder (SUD) provider webinar on all of this as soon as possible, since many critical issues and outstanding questions remain.
Nebraska started work requirements early. Here’s how it’s going
September 22, 2026 05:00 AM CDT
Key Takeaways
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- Nebraska instituted Medicaid work requirements in May, seven months earlier than federally mandated.
- Patient advocates say the rollout has revealed flaws in the state’s implementation.
- Providers report dealing with confused patients who need assistance complying with work requirements.
An early effort to implement Medicaid work requirements in Nebraska is causing confusion and anxiety, according to providers and patient advocates.
Under President Donald Trump’s signature tax law, most adult Medicaid beneficiaries eligible under the Affordable Care Act of 2010 expansion and other expansions in a handful of states will be subject to work requirements nationwide in January. Nebraska went first and launched its program this May. Montana followed in July, while Arkansas started screening applicants and enrollees the same month but is not enforcing penalties until next year. Georgia had a different form of work requirements already in place.
Medicaid stakeholders have looked to Nebraska as a bellwether for national implementation. So far, providers and patient advocates point to sparse state data on how it’s progressing, federal and state policy discrepancies, and long wait times for Medicaid call center assistance as evidence that the rollout has been rocky.
“The rushed implementation has clearly caused significant issues in our state,” Sarah Maresh, program director for healthcare access at the advocacy group Nebraska Appleseed.
Enrollment information
About 70,000 enrollees in Nebraska are included in the expansion population.
The state began requiring new applicants to meet work requirements or prove eligibility for an exemption beginning May 1. People already enrolled started to become subject to the work rules on July 31.
To date, Nebraska and the Centers for Medicare and Medicaid Services have made little data available on the effects of work requirements on enrollment. Figures will become publicly available in the coming weeks, according to a Nebraska Department of Health and Human Services spokesperson. CMS did not respond to a request for comment.
Between July 1 and Aug. 30, 643 Medicaid expansion enrollees lost coverage for failing to meet the work requirements, a Nebraska Department of Health and Human Services spokesperson wrote in an email.
Nebraska processed 6,985 new applications from May through July, according to state records. The state denied 3,615, including 336 due to work requirements and 3,279 for “any other reason,” such as procedural denials or ineligibility based on income.
The state has issued several short-term hardship exemptions with CMS approval. For instance, Dawson County is temporarily exempt due to high unemployment rates following the closure of a meatpacking plant.
For verifying “medical frailty” exemptions, the state compiled a 300-page list of billing codes it cross-checks against up to 12 months of claims, then contacts enrollees if they need more information. Nebraska also allows applicants to self-attest that they are medically frail.
Nebraska is not hiring additional staff to oversee verification. Employees have “received extensive training on Medicaid work requirements, including new policy requirements, system workflows, verification standards and member assistance procedures,” the Nebraska Department of Health and Human Services spokesperson wrote.
Policy confusion
Providers and advocates say confusion and misinformation abounds about who is subject to work requirements and how to comply, even among state caseworkers. Plus, hours-long call center wait times impede communications between enrollees and the state, Maresh said.
Nebraska has also run into some trouble with federal authorities, which didn’t publish the rule governing work requirements until months after the state started implementing them.
CMS has notified the state that some aspects of its program, such as its medical frailty policies, do not comply with the regulation. CMS gave the state 30 days to explain how it will align with federal requirements.
The Nebraska Department of Health and Human Services is reviewing the regulation and subsequent guidance to determine if any immediate changes are needed, the spokesperson wrote. “[The department] plans to make changes to the verification process over the next year in response to the [rule] and will share updates as available,” he said.
Providers
Community health centers are fielding more pleas for help with navigating the verification systems enrollees and applicants must use to report their work records, said Health Center Association of Nebraska CEO Amy Behnke. They’re also starting to see a decline in patients with Medicaid, though that’s likely due to a mixture of work requirements and other factors, she said.
These clinics are closely monitoring their case mix and are maximizing operational efficiencies so they can stretch their finances as far as possible, and they are doing everything they can to ensure all Medicaid enrollees and eligible applicants are getting or retaining their coverage, Behnke said.
But enrollment losses will cause financial harm as uninsured patients rely more on sliding-scale payment plans, Behnke said.
Pender Community Hospital has been training staff on work requirements and educating enrollees to help mitigate fallout, said Laura Gamble, the critical access hospital’s CEO. Although Gamble hasn’t seen a significant uptick in uncompensated care yet, she’s bracing for impact as more enrollees go through eligibility checks.
“We’re going to probably be sending more people to collections. We’re preparing that we’re probably going to be seeing more people that will have to be on charity care or write-offs. We don’t like to send anybody to collections. That is not our goal,” Gamble said. “That’s why we’re trying to do the education with the people that have Medicaid.”
The administrative effort to help patients understand work requirements is also pulling staff away from clinical work that could have been reimbursable, which is causing “a little bit of a financial strain,” said Chris Tonniges, president and CEO of Omaha-based Lutheran Family Services, which provides mental and behavioral health services among other offerings.
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Inside CMS’ medical frailty, Medicaid work requirements guidance
Modern Healthcare, 9/14
Key Takeaways
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- The Centers for Medicare and Medicaid Services issued new guidance last week to aid states implementing Medicaid work requirements.
- The guidance focuses on how enrollees and states can manage exemptions to the work requirements for “medical frailty.”
- The document offers a blueprint for medical frailty determines but leaves key questions unanswered.
The Centers for Medicaid and Medicare Services has provided the greatest detail to date about how states can determine who is exempt from Medicaid work requirements for “medical frailty.”
The guidance, issued in the form of a slide presentation last Tuesday, offers a blueprint for states as they hustle to figure out how to implement the “medical frailty” exemption, which has been a sticking point. Yet it leaves many questions for states, providers and insurers to sort out.
Work requirements must be in force no later than Jan. 1 under President Donald Trump’s signature tax law, leaving states with little time to get ready to cull the Medicaid rolls and to manage exceptions to the rule.
Related: How Medicaid work requirement prep is straining states
The law includes a narrow set of exemptions for enrollees who are too old, too young or too sick to meet the requisite 80 hours of work, school or volunteering per month. One key exemption is for medically frail beneficiaries.
The statute defines a person as medically frail if they have at least one of these five characteristics: a physical disability, substance use disorder, a disabling mental health condition, an impairment impeding activities of daily living or a “serious or complex” illness.
But the interim final rule to implement work requirements created a strict two-part test to determine medical frailty. Enrollees must meet one of the criteria in statute and also verify that the underlying condition significantly impairs their ability to work or participate in other qualifying activities.
The new guidance offers greater clarity about how the agency will judge how states manage medical frailty decisions and suggests an optional, three-tiered approach to promote compliance.
The first includes instances when states can confirm enrollees are significantly impaired based on a code alone, such as people being treated for ALS or pancreatic cancer.
Tier two includes baseline billing codes that could qualify an enrollee as medically frail, but for which the state may require additional information to make a determination.
The third tier involves situations in which the state doesn’t have enough information to discern medical frailty.
CMS also recommends data states could use to verify medical frailty, such as ICD-10 codes, fee-for-service and Medicaid managed care claims, and short-term disability claims.
“Because an exclusion on the basis of medical frailty depends on whether a health condition or conditions significantly impairs an individual’s ability to comply with the community engagement requirement, determining whether an individual qualifies for the exclusion may require consulting multiple data sources,” the guidance says.
There are real positives to the new information, said Kinda Serafi, a partner at the legal and consulting firm Manatt Health. The guidance gives states a practical roadmap for using diagnoses, claims, utilization data and other information to help make medical frailty determinations, she said.
While this gives states a jumping-off point, it presents challenges.
For instance, CMS makes clear that states must develop their own verification methodologies and code lists, which creates compliance risks for states, Serafi said.
“Without granular guidance from CMS, they’re going to be asked to make thousands of clinical and policy judgments, and there’s a real possibility that those decisions are going to be scrutinized years later,” Serafi said.
The suggested tiers also leave questions for states to hash out.
States will have to decide the extent to which they plan on instituting a tiered structure, said Susan Dentzer, president and CEO of America’s Physician Groups. They’ll need to set parameters for each tier and determine whether they will partner with physicians and managed care organizations, Dentzer said.
In practice, the tiers are clearer-cut than patients’ conditions occur in reality, and this approach puts providers in an ethically difficult position when patients need clinical evaluations to document they are exempt from work requirements, Dentzer said.
“This violates every principle of medical ethics known to humankind,” Dentzer said. “It’s going to put clinicians in the position of sitting as judge and jury over whether their patients not only can work or not but, frankly, whether they can still be on Medicaid.”
Technology vendors will need to establish analytics that capture both diagnosis codes and ongoing claims information, since CMS requires significant detail on enrollees’ medical histories, many of whom go in and out of care as their condition changes, Susan Harrison, an associate director in Guidehouse’s State Health and Human Services practice, wrote in an email.
Medicaid managed care organizations have significant data readily available, so communication and data-sharing with insurers could play a crucial role, but that requires a lot of foresight and planning by states that just isn’t there yet, said Emma Liebman, associate director of policy for the Alliance of Community Health Plans, which represents provider-affiliated health insurance companies.