Last year’s H.R. 1 legislation set up new work requirements for Medicaid recipients that states need to implement by January 1, 2027. Nebraska is the first state to implement these requirements. This was no small ask. With over 70,000 Nebraskans impacted, this brought added attention from Centers for Medicare and Medicaid Services (CMS) and a pressure for a smooth roll-out of the changes. Cross-divisional staff from Nebraska’s Department of Health and Human Services (DHHS) including IT and operational project managers, health service experts, operations staff, a program accuracy team, eligibility operations experts, and trainers worked collaboratively to implement the new Medicaid work requirement. Thanks to a long-standing relationship with Nebraska, PCG supported the state in achieving this by reviewing the new requirements and working with teams to create clear guidance for in Nebraska.

The expedited timeline created some challenges. “Being that we were on an expedited timeline, we took a white smoke approach,” explained Senior Consultant, Latanya Michaux.  “We held ‘white smoke’ meetings three days a week for three hours each to review, create, and approve requirements and ensure project deliverables were met timely. Outputs from the white smoke sessions, especially business and operational decisions, aided in the development of guidance.”

PCG experts worked with the Department to develop new guidance to give to workers and inform training. Since this is a new requirement two process guides were developed: one for initial Medicaid applications and one for Medicaid renewals. Both included clear, step-by-step instructions on how to process applications and renewals which were released in phased approaches ahead of the implementation date. Along with the guides, system enhancements were also made to assist in determining Medicaid Work Requirement compliance.

The strong relationship with DHHS was key to a successful roll-out. Workers were included in various meetings to walk through the newly created processes and procedures. “Having the workers attend various meetings, allowed for pointed discussions and suggested edits for successful delivery of the new processes and procedures. They (the workers) pointed out some things that needed attention or when we were missing something. So that was beneficial for the team,” said Michaux. Staff members were empowered to escalate questions and concerns about the process, and the team used this feedback to make changes to increase clarity in the guides.

Another complicating factor was that Nebraska implemented the new requirements before the final guidance from CMS was released. The team had to be ready to change direction quickly, due to the fluid state of guidance coming from CMS. The team had to work off of some assumptions, but had a dynamic relationship with CMS, which ultimately helped minimize confusion. Final guidelines were recently released and PCG is currently reviewing them to ensure accuracy and consistency in Nebraska’s new guides.  Daily check-ins with DHHS are ongoing and adjustments are still being made.

Implementing work requirements for the first time had the potential to be a major strain on DHHS. Nebraskans are concerned about the new requirements and their ability to maintain their coverage. Despite the staff learning the new requirements at the same time as the public, DHHS’s communication team was able to alleviate many concerns. Michaux shared how their outreach strategy helped build trust with the public: “Kudos to the communications team. They really did a fantastic job of putting out Q&As. Outreach letters were sent to beneficiaries and the Department’s website was updated which allowed for useful resources for the public to rely on.”

Additionally, the open collaboration and deep partnership between PCG and DHHS allowed for a successful implementation “There’s a lot of trust and respect amongst the team, whether we’re PCG, whether we’re Nebraska – we’re all working as a unit,” Michaux said. “We knew what we had to do. We knew that we were tired. We knew that we were decision fatigued, but at the end of the day, there was a requirement that we had to meet. I really cannot brag enough about how well Nebraska handled this requirement. PCG has established an incredible relationship with Nebraska. And I think that’s, what has helped.”

Michaux is presenting on this project later this summer at the 2026 Medicaid Enterprise Systems Conference.

To learn more about this work:

PCG State Health and Medicaid Services