Expanding Medicaid in Nebraska and the Fight to Stop Harmful Waivers, Tiered Benefits

Expanding Medicaid in Nebraska and the Fight to Stop Harmful Waivers, Tiered Benefits

This blog is part of our Working Better Together series and was authored by Sarah Maresh, Health Care Access Program Director at Nebraska Appleseed. This blog series is intended to provide our Health Law Partners with a platform to highlight successes, challenges, and innovative approaches to furthering health access and health equity in the states where they work.

Nebraska Appleseed is a nonprofit legal advocacy organization that fights for justice and opportunity for all Nebraskans. We do our work where it does the most good – in the courthouse, in the legislature, and in the community. We leverage our legal skills, lobbying, and grassroots organizing to promote positive systemic change and defend against harmful policies or proposals. One of our core priorities is ensuring that all Nebraskans have access to quality, affordable health care. A vital component of this work is ensuring that Medicaid works well for the hundreds of thousands of Nebraskans who rely on this program for their health care.

Advocating for Robust Health Care Policy for More People with Greater Services

Over our 25-year history, Nebraska Appleseed has filed significant impact litigation to improve access to health care in our state. A few of our past major legal victories include: ensuring that former foster youth in Nebraska have access to Medicaid until age 26; protecting the right of all pregnant people in Nebraska to receive prenatal care regardless of immigration status; securing the right of all children with Medicaid in Nebraska (and especially those with developmental disabilities and autism) to obtain necessary behavioral and mental health care services; and defending the rights of medically needy caretakers to receive Transitional Medical Assistance through Medicaid.

The Fight for Medicaid Expansion in Nebraska

After nearly a decade of advocacy, including a recent lawsuit, over 72,000 Nebraskans are now enrolled in Medicaid expansion coverage, and they can access the full scope of benefits without having to meet or prove an exemption to requirements. For years, Nebraska Appleseed advocated alongside community members for Medicaid expansion through state legislative efforts, which were ultimately unsuccessful. The issue was taken to Nebraska voters in 2018, who approved a ballot initiative to expand Medicaid to an estimated 90,000 Nebraskans, joining 34 other states that had already adopted Medicaid expansion. Unfortunately, Nebraska’s implementation of Medicaid expansion prompted the need for legal action. Despite the will of the people, Nebraska delayed implementation for nearly two years and pursued an unnecessary and complicated Section 1115 Waiver. 

Ensuring Medicaid Expansion Provides a Full Range of Benefits – Working with NHeLP to Stop Tiered Benefits

In October 2020, Nebraskans finally received access to Medicaid expansion coverage and started receiving medical care. But for many Nebraskans, Medicaid expansion coverage still did not include access to dental, vision, and over-the-counter drug benefits, which are all benefits that Nebraska Medicaid usually covers. Before its Section 1115 Waiver was approved, Nebraska implemented a tiered benefits system that involved two separate benefits packages for the expansion group – prime and basic. Prime coverage, which included all Nebraska Medicaid state plan benefits, was available for those who had been determined medically frail, were pregnant, or were 19 or 20 years old. Every other enrollee got basic coverage, which did not include dental, vision, or over-the-counter drug benefits. The importance of this care is obvious. While vision and dental care are essential for healthy eyes and mouths, general health conditions have impacts on vision and dental health, making regular vision and dental care key to overall health. Over-the-counter drug coverage is also imperative in managing chronic conditions or treating illness.

Engaging the Community in the Administrative Comment Process

Nebraska Appleseed conducted extensive outreach to providers, community organizations, and community members using accessible materials and presentations to inform Nebraskans about the Section 1115 Waiver and engage Nebraskans in administrative comment processes. Many Nebraskans spoke out in opposition to the Section 1115 Waiver that would have required people in the Medicaid expansion group to meet or prove exemptions to onerous work, personal responsibility, and wellness requirements to be eligible for important vision, dental, and over-the-counter drug benefits.  Despite intense opposition, Nebraska submitted its waiver to the federal government for approval. After receiving 425 public comments, 424 of which were in opposition, the federal government approved the waiver on October 20, 2020. 

Challenging Unlawful Tiered Benefits with NHeLP

Together with the National Health Law Program, Nebraska Appleseed filed a lawsuit challenging Nebraska’s tiered benefits system in February 2021. The case was filed on behalf of two named clients, together with a motion for class certification that would expand the case to include all Nebraskans enrolled in Medicaid expansion coverage – at least 90,000 people. However, days before a major hearing in the case, the State announced they were voluntarily ending the tiered benefit system and were planning to provide full benefits to all Medicaid expansion enrollees – including dental, vision, and over-the-counter drug benefits. The State also announced it was abandoning its harmful Section 1115 Waiver, which sought to impose work requirements and other barriers on Medicaid expansion enrollees. 

In October 2021, over 39,000 Nebraskans finally gained access to critical dental, vision, and over-the-counter drug benefits.

We will continue to fight to keep our Medicaid program strong because we know that our state’s strength depends on the health and well-being of all Nebraskans. 

Working Better Together Blog Series

The Working Better Together blog series gives our Health Law Partners a platform to highlight successes, challenges, and innovative approaches to furthering health access and health equity in the states where they work. Find other blogs in the series here.

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