Nebraska made history on May 1, 2026, becoming the first state in the country to enforce Medicaid work requirements under a federal law passed as part of the 2025 budget reconciliation package. For most Medicare beneficiaries, this might sound like a distant policy debate — but if you are one of the roughly 12 million Americans who are dually enrolled in both Medicare and Medicaid, this development deserves your full attention. Dual-eligible individuals rely on Medicaid to cover costs that Medicare does not — things like nursing home care, home health aides, dental services, vision, and the monthly premiums and cost-sharing that Medicare itself charges. Anything that disrupts Medicaid eligibility can directly affect what you pay out of pocket, and in some cases, whether you can afford care at all.
The 2025 reconciliation law requires states to condition Medicaid eligibility for adults in the ACA Medicaid expansion group — and enrollees in certain waiver programs — on meeting work requirements or qualifying for a defined exclusion. The federal deadline for all states to comply is January 1, 2027, but Nebraska chose to move early. That makes Nebraska a live laboratory, and the early data presented at the state's September 2026 Medicaid Advisory Committee meeting offers the first real-world look at how these requirements play out in practice. The numbers are instructive — and in some cases, alarming.
Among Nebraska Medicaid enrollees subject to the new work requirements, 46% of new applicants and 34% of individuals renewing coverage were able to demonstrate they met qualifying activities. Nebraska defines qualifying activities as working at least 80 hours per month, having a monthly household income of at least $580, or attending school. That is a meaningful share of people who cleared the bar — but it also means the majority of people subject to the requirement did not meet it through work activity alone. The good news is that a large portion of those individuals qualified for an exclusion instead.
Exclusions from the work requirement include being a parent of a child under age 14, being classified as medically frail, and other defined criteria. Among new applicants, 39% qualified for an exclusion; among those renewing coverage, that figure jumped to 57%. This aligns with longstanding research from KFF showing that most Medicaid adults under age 65 are either already working or face documented barriers to employment — such as caregiving responsibilities, disability, or chronic illness. The work requirement, in theory, was designed to identify people who are neither working nor facing barriers. In practice, the Nebraska data suggests that group is relatively small.
But here is where the data gets concerning: 14% of new applicants and 7% of individuals renewing coverage had their applications denied or lost coverage because they did not meet work requirements. That is not a rounding error. In a state with hundreds of thousands of Medicaid enrollees, even a 7% disenrollment rate among renewals represents a significant number of people losing access to healthcare. And critically, the data does not tell us why those individuals failed to meet the requirements. Were they genuinely ineligible? Or did they miss a paperwork deadline, fail to receive a notice, or simply not understand what was being asked of them? Only 2% of both new applicants and renewals received a short-term hardship exception, suggesting that safety valve is being used sparingly.
The verification process Nebraska uses is worth understanding in detail, because it directly affects whether you keep your coverage. Nebraska uses a combination of automated data checks and self-declaration forms. When the state can automatically verify that someone meets the work requirement or qualifies for an exclusion — using data it already has on file — it sends an approval notice and the enrollee does not have to do anything. But when the state does not have enough information, it sends a notice asking for more details, along with a declaration form. That form must be returned within 30 days. If you miss that 30-day window, your application can be denied or your coverage can be terminated — even if you would have qualified. This is the single most important procedural fact for dual-eligible beneficiaries to understand: the deadline is real, and missing it has immediate consequences.
Data Snapshot: According to CMS.gov data, there were approximately 12.5 million full-benefit dual-eligible beneficiaries enrolled in Medicare as of 2024. D-SNP enrollment has grown substantially year over year, with more than 6 million beneficiaries enrolled in Dual Eligible Special Needs Plans in 2025 — up from roughly 4.8 million in 2023. These are real people whose Medicare coverage is directly tied to their Medicaid status. A disruption in one program ripples immediately into the other.
For dual-eligible Medicare beneficiaries specifically, losing Medicaid coverage mid-year can trigger a cascade of financial consequences. If you are enrolled in a Dual Eligible Special Needs Plan — a type of Medicare Advantage plan designed specifically for people who have both Medicare and Medicaid — losing your Medicaid eligibility may mean losing your D-SNP enrollment as well. D-SNPs typically offer $0 premiums, reduced cost-sharing, and extra benefits like dental, vision, hearing, and non-emergency medical transportation that standard Medicare Advantage plans may not provide. Losing that coverage could mean reverting to Original Medicare with no supplemental coverage, or scrambling to find a new plan during a Special Enrollment Period. The financial exposure can be significant: Original Medicare's Part A hospital deductible in 2025 is $1,676 per benefit period, and there is no out-of-pocket cap unless you have supplemental coverage.
The federal rule also contains an important timeline shift that beneficiaries should know about. Through the end of 2027, states are permitted to accept self-declaration — meaning you can attest on a form that you meet the work requirement or qualify for an exclusion, without submitting supporting documents. But starting in January 2028, except for medical frailty determinations, states must request actual documentation when they do not already have data on file. That means the process will become more burdensome in 2028, not less. If you are in a state that has not yet implemented work requirements, expect the documentation demands to increase over time, and start organizing relevant records now.
Every state will handle implementation differently, and that matters enormously. Some states may adopt more generous exclusion criteria or longer response windows; others may mirror Nebraska's approach closely. Your state Medicaid agency is the authoritative source for how requirements will apply to you specifically. Most state Medicaid agencies have dedicated phone lines and online portals where you can check your eligibility status, update your information, and submit required forms. If you receive any notice from your state Medicaid office asking you to verify your work status or submit a declaration form, treat it as urgent. Do not set it aside. A missed 30-day deadline can cost you your coverage, and in Nebraska's early data, that appears to be exactly what happened to a portion of the 14% who were denied.
If you believe you qualify for an exclusion — because you are a caregiver for a young child, because you have a medical condition that limits your ability to work, or because you meet another defined criterion — document that clearly when you respond to any state notice. If you are unsure whether you qualify for an exclusion, contact your State Health Insurance Assistance Program counselor. SHIP counselors are free, unbiased, and trained specifically to help Medicare and dual-eligible beneficiaries navigate exactly these kinds of situations. You can find your local SHIP counselor at shiphelp.org or by calling 1-800-MEDICARE (1-800-633-4227). These counselors can also help you understand your appeal rights if your Medicaid coverage is terminated — and appealing promptly matters, because in many states you can maintain coverage during the appeal process.
It is also worth noting what the Nebraska data does not yet tell us. We do not know the health outcomes for the 14% of new applicants who were denied. We do not know how many of those individuals were actually ineligible versus how many simply could not navigate the paperwork. We do not know how many will successfully appeal. And we do not know how the numbers will shift as the process matures and more states come online. Researchers and policy analysts will be watching Nebraska closely over the coming months, and additional data from the state's Medicaid Advisory Committee meetings will likely shed more light on these questions. What the early data does confirm is that the administrative burden of work requirements — independent of whether someone is actually eligible — is causing real coverage losses.
For beneficiaries approaching the 2027 federal deadline, the most important steps are straightforward: confirm which Medicaid eligibility category applies to you, because not all dual-eligible seniors are subject to work requirements; update your contact information with your state Medicaid office so notices reach you; and respond to any correspondence within the stated deadline. If you are enrolled in a D-SNP, ask your plan's member services line what happens to your enrollment if your Medicaid status changes, and what Special Enrollment Period options would be available to you. The Annual Enrollment Period runs October 15 through December 7 each year, and the Medicare Advantage Open Enrollment Period runs January 1 through March 31 — but a loss of Medicaid eligibility typically triggers a separate Special Enrollment Period that allows you to make changes outside those windows.
What we know with certainty is this: the era of automatic Medicaid renewal without active verification is changing. Whether you support or oppose work requirements as a policy matter, the practical reality is that staying enrolled in Medicaid — and by extension, protecting your dual-eligible Medicare benefits — now requires active engagement. Open your mail. Respond to notices promptly. Know your exclusion rights. And if you need help, reach out to a SHIP counselor or your state Medicaid office before a deadline passes. Nebraska's early data is a warning. The rest of the country has until January 2027 to prepare.