On October 20, 2020, CMS approved Nebraska’s Medicaid expansion program – named the “Heritage Health Adult,” or HHA – under Section 1115 of the Social Security Act, creating a new two-tiered system of Medicaid benefits for the expansion population. The HHA offers enhanced, demonstration-only benefits on a voluntary basis intended to a subset of individuals in the adult group expansion population. The expansion program will begin on April 1, 2021 and comes on the heels of a 2018 initiative (Initiative 427) and statewide vote in favor of a Medicaid adult group expansion. CMS’s October 20, 2020 approval of Nebraska’s HHA program is effective until March 31, 2026, unless extended or amended.

In April 2021, a subset of Nebraska’s Medicaid expansion population will be able to enroll in an enhanced package, the “Prime” coverage that comes in exchange for meeting certain requirements, or to enroll in the “Basic” package (the approved Alternative Benefit Plan, or ABP). The more traditional “Basic” package is comprised of physical and behavioral healthcare services and prescription drugs that includes mandatory Medicaid benefits. The “Prime” package requires wellness and community engagement, work or education-related activities in exchange for the Medicaid benefits that are available under the Nebraska state plan as well as the following additional benefits that states are not required to include in benefit plans for the adult group expansion population:

• Vision services, including optometrist services and eyeglasses;
• Adult dental services, including dentures; and
• Over-the-counter medications.

Adults ages 19 to 20, or who are medically frail or pregnant, will receive the “Prime” coverage without satisfying the newly announced requirements and are not part of the demonstration program. Adults ages 21 to 64 who are not medically frail or pregnant and who have an income at or below 138% of the federal poverty level are eligible to voluntarily select the “Prime” coverage option and in exchange for satisfying wellness and community engagement, work or education-related activity requirements. Beneficiaries who choose not to elect the “Prime” coverage will not lose their Medicaid eligibility.

Beginning in April 2021, enrollees who elect the “Prime” package in the demonstration program must complete wellness initiatives. This includes attending annual wellness visits, maintaining their employer-sponsored coverage, completing risk assessments, and avoiding missing most scheduled appointments. Beginning in April 2022, to receive the additional “Prime” benefits, enrollees must “engage in sufficient qualifying community engagement activities.” Specifically, the activities include education, work, or job-seeking requirements with a minimum hourly per month commitment of 80 hours. Enrollees will also be required to participate in community engagement activities unless they can meet one of several “good cause” exemptions for such engagement activities, which could include:

• Individuals in substance use disorder or mental health treatment programs;
• Individuals receiving unemployment compensation or are meeting requirements in the waiting period;
• Members of a federally recognized tribe;
• High school students (attending school at least half time);
• Individuals aged 60 to 64;
• Individuals in an area with a federal SNAP Able-Bodied Adults without Dependents (ABAWD) waiver grant;
• Individuals who are victims of domestic violence in certain circumstances;
• Parents, caretakers, guardians, or conservators of dependent children, elderly, or disabled relatives; or
• Individuals in the SNAP Employment and Training program or otherwise meeting AWAWD requirements.

Such “Prime” beneficiaries will also be required to notify Nebraska’s Medicaid agency of any changes that will affect their eligibility for demonstration-only benefits.

Nebraska reports that its Medicaid expansion will enroll an additional 90,000 lives in its Medicaid program (which currently enrolls approximately 221,000 people). Nebraska anticipates that most benefits will be provided through its Medicaid managed care program (Heritage Health), with dental benefits flowing through MCNA. CMS announced that the community engagement activities are designed with enrollees’ overall wellness in mind to “help lift them from poverty and put them on a road to improved health and independence.” CMS noted in its approval letter that the COVID-19 pandemic could affect this community engagement requirement, but also noted that “recent research during the COVID-19 pandemic indicates that factors such as a lack of economic participation, social isolation, and other economic stressors have negative impacts on mental and physical health.”

Additional resources and information from Nebraska’s Department of Health and Human Services related to the “Basic” and “Prime” benefits are available here. Nebraska’s HHA original concept paper is available here. Because Medicaid-related work requirements have often faced legal challenges, King & Spalding will continue to monitor and report on the status of Nebraska’s new program.