Montana began enforcing work requirements for Medicaid expansion recipients on July 1, putting in place a policy that the state legislature first sought more than six years ago but that only became viable after Congress acted this year.
Background
Montana lawmakers approved community engagement requirements for Medicaid expansion during the 2019 legislative session, but the state never obtained the federal waiver needed to move forward. That changed when Republicans in Congress passed the federal budget reconciliation package widely known as the “One Big Bill,” which mandated that states implement work requirements for expansion populations. The original federal deadline for compliance was January 1, 2027, though Montana moved ahead of that target.
Who Is Affected
Under the new rules, most Medicaid expansion enrollees between the ages of 19 and 64 must document at least 80 hours per month of qualifying activities. Those activities can include employment, education, job training, or volunteering.
Several categories of enrollees are exempt from the requirement: pregnant women, parents or caregivers of children younger than 14, American Indians, and individuals with health conditions that limit their ability to work or meet the activity threshold.
As of March, Montana had approximately 207,902 people enrolled across Medicaid and the Healthy Montana Kids programs. Of those, roughly 73,895 were adults enrolled specifically in Medicaid expansion — the population directly subject to the new requirements.
The Rollout
The state Department of Public Health and Human Services began mailing outreach materials to Medicaid members in March to notify them of the coming change. The department operates 19 local Offices of Public Assistance across the state and maintains an online portal at apply.mt.gov as well as a Public Assistance Helpline at 1 (888) 706-1535.
A three-month “hold harmless” period runs through the end of September. During that window, enrollees who are not meeting the documentation requirements will be notified but will not immediately lose coverage. Beginning in October, noncompliance could result in disenrollment.
DPHHS Director Charlie Brereton said the agency is ready for the transition. “The Department is fully prepared for this transition, with trained staff, clear exemption processes, and systems ready to support members,” he said.
Concerns About Implementation
Not everyone shares that confidence. Heather O’Loughlin, executive director of the Montana Budget and Policy Center, raised concerns about administrative barriers that could cause eligible recipients to lose coverage through no fault of their own. “What we know is that many folks who would be considered in compliance or meet an exclusion are often the ones who ultimately lose coverage, because they miss the paperwork or face challenges in really reaching the department and getting answers that they need,” she said.
The concern reflects a pattern documented in other states that have implemented similar requirements — where enrollment losses have sometimes been driven less by actual ineligibility than by difficulty navigating the documentation process. Montana health policy advocates have urged the state to invest heavily in outreach to ensure that workers, caregivers, and others who qualify for exemptions are not inadvertently dropped.
What Comes Next
The hold harmless window gives enrollees and state agencies approximately three months to work through compliance issues before coverage terminations become a real possibility. DPHHS has indicated it will continue outreach efforts throughout that period.
Montana’s Medicaid expansion, which extended coverage to low-income adults who do not qualify for traditional Medicaid, has been a recurring flashpoint in state politics. The Legislature has reauthorized the program multiple times, often with conditions attached — the 2019 work requirement provision being one example. The federal mandate now removes the ambiguity that previously blocked state action, setting up October as a critical test of whether the implementation machinery DPHHS has built can protect eligible recipients while achieving the policy’s stated goal of encouraging workforce participation.
Broader questions about how Montana manages state-federal health and social service programs have drawn attention in recent months, including scrutiny of delayed reimbursements in the state’s childcare payment system that have strained providers across the state.
