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CMS Approves Nebraska Medicaid Demonstration to Provide Pathway to Enhanced Benefits for Eligible Adults

Today, the Centers for Medicare & Medicaid Services (CMS) announced its approval of Nebraska’s new Medicaid Section 1115 demonstration called “Heritage Health Adult.” This demonstration is designed to create a pathway for certain Nebraska adults with newly gained Medicaid coverage to access additional benefits if they participate in certain activities to promote health and independence. This demonstration is effective October 20, 2020, through March 31, 2026, with implementation beginning April 1, 2021.

“Governor Ricketts and his team deserve credit for responding to President Trump’s invitation to design innovative state-led solutions that promote health and well-being among Medicaid beneficiaries,” said CMS Administrator Seema Verma. “The Nebraska demonstration is a unique model designed to provide a voluntary pathway to added benefits for certain adult beneficiaries who participate in wellness activities, as well as work and take part in other community engagement activities, which can help lift them from poverty and put them on a road to improved health and independence.”

This demonstration applies to an important but limited population: adults who are not medically frail or pregnant, ages 21 through 64, and who are eligible under the Medicaid adult group expansion—having income at or below 138 percent of the federal poverty level. Low-income adults who are 19 or 20 years old and/or medically frail, children, pregnant women, elderly adults, and others eligible on the basis of a disability will not be affected by the demonstration and already have access to the additional benefits listed below. Additionally, Heritage Health Adult beneficiaries will not lose Medicaid eligibility if they choose not to participate in the voluntary incentive opportunity provided under this demonstration. All Heritage Health Adult beneficiaries will receive a comprehensive set of Medicaid benefits that meets federal benefit standards, including doctor’s office visits, hospitalization, prescription drugs, and more.

Qualifying Heritage Health Adult beneficiaries will receive these additional benefits under the demonstration:

  • Vision services (including optometrist services and eyeglasses)
  • Adult dental services (including dentures)
  • Over-the-counter (OTC) medications 

To gain these benefits, starting April 1, 2021, demonstration beneficiaries must participate in these beneficiary engagement activities:

  • Wellness initiatives (attend an annual health visit and complete a health risk assessment)
  • Personal responsibility activities (maintain affordable employer-sponsored coverage, if available to a beneficiary, and not miss more than three scheduled health appointments in a six-month period).

Starting April 1, 2022, beneficiaries must also participate in community engagement activities and notify the state Medicaid agency in a timely manner of any changes that would affect eligibility for the additional benefits.  Beneficiaries with circumstances limiting their ability to meet the community engagement requirement may request an exemption, and beneficiaries who fail to meet one or more beneficiary engagement requirements (including but not limited to community engagement) may request a good cause exception so that their access to the additional benefits under the demonstration will not be affected.

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