LINCOLN, Neb. - Nebraska residents who qualify for voter-approved Medicaid expansion coverage will have to wait 18 months and may have to get a job if they want some benefits under a state proposal that drew immediate criticism Monday from supporters of the federal health care law.

Officials with the Nebraska Department of Health and Human Services announced plans to bring the new system live on Oct. 1, 2020. The long timetable and additional requirements imposed on some recipients was blasted by leaders of the state's Medicaid expansion ballot campaign, who said they were looking at ways to challenge it.

"This is not acceptable and in violation of the law and completely against the clear will of the people that enacted Medicaid expansion," said state Sen. Adam Morfeld, of Lincoln.

Nebraska's proposal creates two tiers of coverage: a "basic" plan for all newly qualified recipients, and "premium" coverage that's only available to people who are working, in school, volunteering or caring for a relative. The premium plan would cover dental and vision appointments and over-the-counter drugs.

State officials defended the plan and the time needed to put it in place.

"Here in Nebraska, it may appear that we need to move expeditiously to implement the expansion," said Dannette Smith, the department's new CEO. "But I can tell you from my experience... it is better for our fellow citizens that we carefully and methodically administer the expansion."

Smith said the department, a part of Republican Gov. Pete Ricketts' administration, wants to ensure the expansion is "fully functional and viable" on its first day. Ricketts vehemently opposed efforts to expand Medicaid in the Legislature but promised to respect the will of voters who approved it in November.

Supporters of Medicaid expansion said the delay will hurt the people who qualified for coverage under the measure. The 2018 ballot measure won support from nearly 54 per cent of voters statewide, although much of the support came from the Omaha and Lincoln areas.

The Nebraska proposal "is irresponsible and contrary to the intent of Nebraska voters," said Molly McCleery, a staff attorney for the group Nebraska Appleseed. "This plan leaves the health of 90,000 Nebraskans who are unable to access health care in jeopardy for two more years."

McCleery said it's disingenuous for Nebraska state officials to argue that they need another 18 months when other states have expanded Medicaid in less time.

She pointed to Medicaid expansion rollouts in Louisiana and Virginia. Both states started providing coverage less than six months after Medicaid expansion was approved. Unlike Nebraska, those states didn't seek the federal government's permission to impose additional requirements on recipients.

Other states, such as Maine and Utah, have taken longer to enact voter-approved Medicaid expansion measures. Former Maine Gov. Paul LePage, a Republican, was accused of dragging his feet for years because of his complaints about the cost . His Democratic successor, Gov. Janet Mills, took several key steps in the expansion process in January.

In February, Utah Gov. Gary Herbert and the Republican-led Legislature approved changes to a voter-approved Medicaid expansion plan that cut the number of eligible people in half and added work requirements.

Nebraska officials argue that the delay is also driven by the need to upgrade computer software, hire additional workers and negotiate additional contracts with groups that will serve the new Medicaid recipients.

Nebraska Medicaid and Long-Term Care Director Matthew Van Patton said the plan was designed to promote "wellness and life success" among those who will use it.

"We care that expansion is done right in Nebraska," he said.

The ballot measure requires the Nebraska Department of Health and Human Services to submit a state Medicaid plan amendment to the federal government to cover newly eligible, low-income Nebraskans.

Once it's in place, coverage will become available to adults ages 19 to 64 who earn up to 138 per cent of the federal poverty level — about $16,753 per year. The federal government is required to pay 90 per cent of the program's cost in 2020 and subsequent years.

Nebraska state officials are working with private "managed care organizations" that will provide health care services on the state's behalf. Nebraska already uses their services for current Medicaid recipients, but state officials now have to amend all of their contracts to cover the newly eligible.

Managed care organizations receive a set amount of money from the state each month to care for Medicaid enrollees — giving them a financial incentive to keep costs low.

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News from © The Associated Press, 2019