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Last year, Congress added a new condition to Medicaid coverage for certain low-income adults: work, study, train, or volunteer for at least 80 hours per month, unless exempt. Nebraska became the first state to put the rule into effect.

Medicaid is a health insurance program jointly funded by the federal government and the states for people with limited income, including children, pregnant people, older adults, and people with disabilities. Under one name, it covers several very different groups.

H.R. 1, formally called the One Big Beautiful Bill Act, was a sweeping tax and spending law signed in July 2025. It extended major tax cuts while reducing federal spending across programs including Medicaid. One of its largest Medicaid savings came from a new work requirement. Supporters argued that certain adults should work, study, train, or volunteer to receive coverage, allowing Medicaid to focus its resources on people who cannot work. The Congressional Budget Office estimates that this provision will reduce federal deficits by $317 billion through 2034.

Put simply: Nebraska now requires certain adults on expansion Medicaid to show one qualifying month of 80 hours work, school, training, volunteering, sufficient earnings, or an exemption when they apply for or renew coverage. Nebraska DHS explains the rule here.

This does not apply to everyone on Medicaid. It applies to Nebraska’s expansion group, called Heritage Health Adult: generally adults ages 19 to 64 with income up to 138% of the federal poverty level. Children, older adults, pregnant people, people covered based on a disability, and other traditional Medicaid populations are not subject to this requirement.

Even within the expansion group, many people are exempt. That includes certain caregivers, people who are medically frail, some former foster youth, tribal members, totally disabled veterans, and people meeting certain SNAP or TANF requirements.

For existing members, Nebraska looks for at least one qualifying month since their last renewal, not 80 hours in every month. For new applicants, the state generally looks at the month before they apply.

Nebraska began applying the rule to new applicants on May 1, 2026. Existing members are checked when their coverage renews, with the first affected coverage periods ending July 31. The rollout continues renewal by renewal through June 2027. DHHS checks its own records first and only asks members for additional information when it cannot verify compliance or an exemption.

Congress’s case for the rule had two parts: changing behavior and saving money.

In H.R. 1, of everything changed in Medicaid, work requirements are projected to save the most money: the Congressional Budget Office estimates they'll cut federal Medicaid spending by $326 billion over ten years, the single largest piece of the law's total Medicaid cuts.

Supporters argue that Medicaid should prioritize people who cannot work while encouraging other adults to work, study, train, or contribute to their communities. Nebraska Governor Jim Pillen has said employment provides purpose, builds independence, and makes people more active members of their communities. He has described the policy as “a hand up, not a handout.” Nebraska’s official announcement lays out that argument here.

Critics argue that taking away health coverage is unlikely to make more people work. When Arkansas introduced a similar requirement in 2018, more than 18,000 people lost Medicaid, but researchers found no significant increase in employment, as per New England Journal of Medicine.

The CBO expects the same basic tension nationally: most affected enrollees will already meet the requirement or qualify for an exemption, but millions could still lose coverage. It estimates that 5.3 million more people will be uninsured in 2034 because of the provision, including many who lose coverage because they cannot navigate the new verification process.

That policy debate sounds abstract. Then a letter arrives.

Milo, a grey schnauzer in Lincoln, called his best friend Biscuit, a corgi (remember him from Medical billing 101

"Biscuit, I got a letter from the state," Milo said. "I'm on Medicaid through the expansion program. Now, when I renew, Nebraska has to confirm I had at least one qualifying month since my last renewal, or that I’m exempt."

"Since when? And wait, they actually mail you a letter?"

"Yeah, DHHS mailed a notice to every expansion member back in January. Nebraska started with new applicants in May. Existing members are checked when they renew. My coverage ends July 31, so I’m in the first group affected."

"So how do you prove it?"

"First, I don't have to do anything unless DHHS asks. The state checks its own records first, wage data, that kind of thing, and if that's enough, it just sends an approval notice. If it's not enough, it mails me a specific notice asking for more, with a form attached. I've got 30 days to send it back."

"How do you send it back?"

A few ways: log into iServe, Nebraska's online portal, and upload it there. Or scan the QR code printed right on the notice. Or mail it in, call it in, or walk it into a local DHHS office. For a job, pay stubs or wage records usually cover it. For school, training, volunteering, or caregiving, I fill out a form called the Declaration Form and send that instead."

"What if you miss the 30 days?"

"Then I lose coverage, and have to reapply and prove compliance all over again to get back on."

Nebraska was first, but other states are already moving.

Montana launched its requirements on July 1, 2026. However, July through September is a hold-harmless period: the state checks compliance but does not deny or end coverage for failing the requirement. But, the catch is Montana requires 80 hours every single month, unless the person qualifies for an exemption. Those consequences begin in October. Montana explains its rollout here.

Arkansas also began a “soft” launch on July 1. It is checking who meets the requirement or qualifies for an exemption, but no penalties will apply until January 1, 2027. Arkansas DHS explains the soft launch here.

Iowa follows on December 1, 2026, but only for people applying on or after that date. Existing Iowa Health and Wellness Plan members begin facing the requirement at renewals scheduled for February 2027 or later. Iowa HHS provides the timeline here.

Georgia already operates a separate work requirement through its Pathways to Coverage waiver. That waiver expires on December 31, 2026, just as the new nationwide federal requirement takes effect. CMS lists Georgia’s waiver dates here.

For every other state and D.C. that covers the affected Medicaid expansion population, the requirement must be implemented no later than January 1, 2027. CMS issued the implementation details through an interim final rule in June 2026. The federal rule is available here.

About 112,600 Nebraskans are enrolled in expansion Medicaid, out of 338,000 total Medicaid enrollees statewide. Nebraska's DHHS estimates 60 to 72 percent of expansion enrollees already meet the requirement, either because they're working, in school, or otherwise exempt. The Center on Budget and Policy Priorities, a nonpartisan research group, estimates 28,000 to 41,000 Nebraskans are at risk of losing coverage, and stresses that risk is driven mostly by paperwork and reporting burden, not by people failing to work.

About 112,600 Nebraskans are enrolled in expansion Medicaid, out of 338,000 total Medicaid enrollees statewide. Nebraska's DHHS estimates 60 to 72 percent of expansion enrollees already meet the requirement, either because they're working, in school, or otherwise exempt. The Center on Budget and Policy Priorities, a nonpartisan research group, estimates 28,000 to 41,000 Nebraskans are at risk of losing coverage, and stresses that risk is driven mostly by paperwork and reporting burden, not by people failing to work.

If you're on Nebraska Medicaid, or you bill someone who is, save this one, your renewal date is the only deadline that matters. We'll keep tracking Montana, Iowa, Arkansas, and Georgia as they hit their own dates.

That's it for this issue. Hit reply. I read everything.

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