Omaha, Nebraska — On Friday, Nebraska became the first state in the country to actually enforce Medicaid work requirements under a law signed by President Trump — eight months ahead of the federally mandated deadline, and before most other states have figured out what they’re doing.
The move puts nursing homes and long-term care providers on alert. Medicaid is the single largest payer in the skilled nursing sector, and any significant reduction in enrollment ripples directly into facilities’ bottom lines and patient census.
What the Requirements Actually Demand
Under Nebraska’s new rules, most Medicaid enrollees between the ages of 19 and 64 who receive coverage through the state’s expansion program must show they work, volunteer, or attend school for at least 80 hours a month. Their eligibility will now be reviewed every six months rather than annually — meaning people can lose coverage faster if their circumstances change.
The state says it will first cross-reference enrollees against employment data it already holds. But somewhere between 20,000 and 28,000 people still need to submit documentation themselves, plus several thousand new applicants each month. Those who don’t respond within 30 days risk having their applications denied or losing coverage they already have.
Exceptions exist for people who are too medically frail to work or in addiction treatment. But advocates say the administrative burden alone will push some eligible people off the rolls — particularly those with complex needs who struggle to navigate paperwork deadlines.
Why Nursing Homes Are Watching
It’s not just about who loses coverage. It’s about what happens next. When Medicaid-eligible individuals lose insurance and delay care, they often show up sicker — and more expensive — at hospitals and skilled nursing facilities down the road.
“The higher the administrative burden, the more likely people are found noncompliant and disenrolled,” said Michael Karpman, a health policy researcher at the Urban Institute. A March report from the institute estimated that Medicaid work requirements nationally could eventually leave 5 million to 10 million fewer people enrolled than would otherwise be covered.
Nebraska’s implementation has drawn scrutiny because it’s moving faster than federal guidance anticipated. Health policy experts and advocates say the state is running so quickly that some key operational details aren’t fully resolved — and that counties and enrollment workers haven’t received complete training.
One Nebraska resident, a 21-year-old mother, told reporters she received a letter warning her that she must meet the work requirements or lose the Medicaid benefits that pay for her insulin and diabetic supplies. She said she took on a part-time job against medical advice in order to keep her coverage.
A National Test Case
Every other state still working through Medicaid work requirement implementation is watching Nebraska. Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said the state “can be used as a lesson for other states, both where things go well and where things don’t go well.”
Nebraska’s Republican Gov. Jim Pillen announced in December that the state would move early, calling it an effort to ensure that “every able-bodied Nebraskan” participates in the community. Nebraska had one of the lowest unemployment rates in the country in February, at 3.1%.
For skilled nursing facilities, the immediate risk isn’t catastrophic — Medicaid work requirements exempt those who are medically frail, which covers most nursing home residents. But the long-term concern is about the broader Medicaid pipeline. If enrollment shrinks nationally, the pool of patients who can afford long-term care through Medicaid shrinks with it. That’s a problem that states warn they don’t have enough administrative capacity to manage — even before the enforcement crunch begins.
The federal deadline for all states to comply with work requirements is January 2027. Nebraska just moved the timeline up — and the results will shape how the rest of the country handles what comes next.
