Not one of the 24 speakers favored the plan proposed by the Department of Health and Human Services.

Carol Windrum of Omaha, like many of the people testifying, said the plan contradicts the law that she and other Nebraska voters passed at the ballot box last year.

“The people of Nebraska spoke loudly and clearly,” she said. “We want Medicaid expansion. No more delays, no two-tiered system, no barriers to providing care for all Nebraskans.”

The proposed system, to be called Heritage Health Adult, would have different benefits and more stringent requirements, including work requirements, than traditional Medicaid. Plans call for coverage to start Oct. 1 next year.

To implement the two-tier system and its work requirements, Nebraska will have to get a waiver from the federal government.

Tuesday’s hearing was the last of four being held to collect comments on the proposed system. Nate Watson, deputy Medicaid director, said the hearings are required as part of the state’s waiver application. He noted that Nebraska has held twice the required number of hearings.

All four hearings have been dominated by opponents of the state plan. Watson said it is typical that people who disagree with something will come to such hearings, while supporters stay home.

Those who spoke at the Omaha hearing objected to the barriers and burdens that the plan would create for people who need health coverage.

They said it would be difficult for patients to comply with the number of requirements needed to get full benefits, while tracking those requirements would be costly and difficult for the state.

Speakers objected to the time it is taking to implement the expansion, saying it means that the state would not get as much federal funding as it could and that people who need care are being forced to wait.

“Health care delayed is health care denied,” said David Corbin, who called the proposal “a poor plan.”

Watson said HHS will respond to all of the comments collected at the hearings, as well as written comments. The state plans to submit the waiver application in December.

As outlined in the state’s draft plan, newly eligible Medicaid patients would start with a basic level of coverage. The coverage would include physical and mental health care and prescription drugs but not dental or vision care or over-the-counter medications.

To qualify for the prime level of coverage, patients would have to meet wellness, personal responsibility and “community engagement” requirements. Compliance would be checked every six months, and failing to meet a personal responsibility requirement would bar patients from prime coverage for 12 months.

Community engagement requirements could be met by working, looking for work, caring for a family member or foster child, volunteering, attending college or taking part in an apprenticeship.

The wellness requirements include a health risk screening and an assessment of social determinants of health, filling prescriptions routinely and having laboratory work done as prescribed. They also include going in for an annual physical and choosing a primary care provider.

The personal responsibility requirements include not missing three or more medical appointments in a six-month period, not dropping private health insurance coverage and promptly notifying Medicaid of any changes that might affect a person’s coverage.

The 2018 ballot measure required Nebraska to expand its Medicaid program as allowed under the federal Affordable Care Act. Those newly eligible are working-age adults without disabilities or minor children whose incomes fall below 138% of the federal poverty level — $16,753 for a single person or $34,638 for a family of four.

Currently, single adults and couples without minor children cannot qualify for Medicaid, no matter their income level. Also barred are parents and disabled people with incomes higher than the current Medicaid cutoff. Noncitizens are not eligible now and would remain ineligible under expansion.