Changes to Medicaid complicate process for those with disability waivers

The passage of the “Big Beautiful Bill” means Medicaid changes are coming.

Starting Jan. 1, 2027, Americans will have to log 80 hours a month of work-related activities like school, volunteering or employment to be eligible for Medicaid.

Proponents of the work requirement say it will help deter fraud and abuse. Others — particularly people with disabilities and those who work with them — say it's not that simple.

Those opposed to the change said that the work requirement adds another hurdle to a process that can already be confusing.

Alana Schriver, executive director of the Nebraska Association of Service Providers, works with organizations that provide services for people with developmental disabilities. She said Medicaid doesn't just cover doctor visits and prescriptions.

“Medicaid also pays for waiver programs, and so for example, our home- and community-based supports and services for individuals with intellectual and developmental disabilities are a Medicaid waiver program,” Schriver said.

Schriver is talking about the Home & Community Based Services (HCBS) waiver, which can help individuals with disabilities and their families access care that emphasizes community support and inclusion.

While people with disabilities do not have to meet the 80-hour-a-month work requirement, they will still need to contend with the new rules to access waiver services.

Applying for Medicaid waivers in Nebraska

To apply for waiver services, Nebraskans must first apply for general Medicaid. If they qualify and get enrolled, they can fill out an HCBS waiver. Two different divisions in the Nebraska Department of Health and Human Services are part of the process. General Medicaid is handled by the Medicaid and Long-Term Care division, and the Developmental Disabilities division reviews the HCBS waivers.

The two divisions aren’t directly linked during the application process. People with disabilities are usually eligible for Medicaid in Nebraska. However, if they’re over the income limit for Medicaid or ineligible for another reason — such as not meeting the new work requirement — they will be denied enrollment and access to waiver programs. If this is the case, they must contact the Developmental Disabilities division to clarify they are qualified for Medicaid through a disability.

Schriver said the process won’t always go smoothly.

“If you can't connect with the right person in time, and you do get kicked out of Medicaid, you are also kicked off your waiver for your home- and community-based services, and you have to reapply for that waiver service,” Schriver said.

Schriver said adding the work requirement could deter applicants who do need services.

Another part of the larger budget bill is a requirement to certify for Medicaid and its waivers twice a year, instead of once a year. Schriver said the application process will essentially become a full-time job.

“You will just round-the-clock be trying to prove that you have a developmental disability, that you are supposed to be on Medicaid, you are supposed to be on the Medicaid waiver,” Schriver said.

Nebraska’s congressional delegation weighs in

Both of Nebraska’s senators, as well as all three representatives, voted in favor of the bill. District 1 Rep. Mike Flood said the bill strengthens Medicaid for low-income children, people with disabilities and pregnant women.

“Individuals in these categories, along with several others, are exempt from the community engagement requirements,” Flood said. “Rather, these requirements will incentivize more able-bodied Americans to participate in society and the American economy, while allowing them to continue to receive Medicaid benefits.”

In an opinion piece published by the Omaha World-Herald, Flood, along with Congressmen Don Bacon and Adrian Smith, said the bill aims to strengthen Medicaid’s long-term stability and integrity through the work requirements, referring to the work requirements instituted by President Bill Clinton in 1996’s Welfare to Work bill.

According to a recent report from the Congressional Budget Office, the new provisions would increase the number of people without health insurance in 2034 by 7.8 million compared to an unchanged Medicaid program.

Of that number, 4.8 million are working-age adults with no dependents who won’t meet work requirements. Around 2.2 million will lose coverage through added red tape — like increased recertification and new enrollment requirements. About 1.4 million are people who do not meet citizenship or immigration status requirements but would have previously had access to coverage in some states.

The value of home and community care

For those with developmental disabilities, there are essentially two options when it comes to care — home- and community-based services or a state-run institution, which for Nebraskans, is in Beatrice. Schriver said home and community care is about a quarter of the cost per person compared to the state-run facility.

“It costs about $385,000 a year to support an individual at the institution,” said Schriver. “We can support an individual in the community with our services for around $96,000 a year.”

The Vocational Development Center — Vodec – is a nonprofit organization whose services can be accessed through an HCBS waiver. Its Omaha location provides daytime care for people with developmental disabilities, helps them find employment and teaches independent living skills.

Micky Jackson, the Services Operations Director for Vodec’s Nebraska location, said Vodec helps people with disabilities find different ways to work.

“If that’s their ultimate goal, to work in the community, then we would start here and help develop skills prior to going out into the community,” Jackson said. “They have the option to either stay and just do the employment services here or jump into community integration activities or support employment.”

Vodec’s in-house employment services usually take place at its workshop. Lately, workshop staff – like James Soula– have been taking apart batteries so they can be recycled.

“[You] take batteries out, clean them out, motherboards or chip boards, whatever they call them,” Soula said. “You take those out and clean them, and you put it in a box, and you get another one, and you pull it out and clean it basically all day.”

Soula has been receiving services at Vodec for about 16 years. He enjoys helping out in the workshop, and his supervisors said he’s a hard worker. Soula also enjoys going out for community activities like football and movies.

“We have a pool table, air hockey table. We do fun and games,” Soula said. “That's during the day. So then just all work the whole week, and we actually have a little fun.”

Vodec is important to Soula, who said he wouldn’t have much to do without it and would likely just sit at home.

Soula is not working in the community now, but Jackson said Vodec is helping him prepare if he chooses to someday. She said changes to waiver services could potentially delay his progress.

“If it were to affect the services that we’re providing, essentially it would affect him not being able to eventually work in the community,” Jackson said.

Jackson said disruptions in services can cause people to lose skills they’ve developed. Right now, she’s uncertain what will happen.

“The fact is, it could potentially negatively affect consumers we serve, and that’s what we do not want to happen,” Jackson said.

She said it is hard to plan ahead when there is so much uncertainty.