Montana Enforces Medicaid Work Rules Early as Coverage Fears Mount

Montana begins enforcing Medicaid work requirements on October 1, ending a three-month grace period and making roughly 71,000 enrollees prove they are working, volunteering or studying at least 80 hours a month — or document that they qualify for an exemption — to keep their coverage.

Montana is the second state to actually enforce the rules, after Nebraska began in May, and one of three — alongside Nebraska and Arkansas — that started ahead of the federal schedule. That gives a handful of states an early preview of what most of the country will confront when the deadline for the rest arrives in January 2027.

Advocates and Democratic lawmakers say the Montana rollout is already showing the failure mode they warned about: notices that contradict themselves, a verification system that is not finished, and a shrinking pool of nonprofits available to help people fill out the paperwork. Eligibility for about half of the Medicaid enrollees up for redetermination could not be verified through existing state data, according to Department of Public Health and Human Services figures through August.

What changes on October 1

Montana soft-launched the requirements in July in what DPHHS called a "hold harmless" period, during which the state did not disenroll anyone. That window closes October 1, when new and existing enrollees must comply and noncompliant recipients face denial or termination, with a 30-day window to prove eligibility.

The rules apply to adults ages 19 to 64 covered on the basis of income, who must document their hours or claim an exemption — being "medically frail," caring for a family member, or another qualifying category. As of October 1, people already enrolled cannot self-attest to medical frailty. They must have a health care provider vouch for them or demonstrate a qualifying diagnosis through insurance claims, a standard that federal authorities left states to define and that providers warned goes beyond simply having a diagnosis. Montana published a preliminary list of qualifying conditions in June and said the list would be updated by October 1.

The same date brings a separate change: refugees and asylum seekers lose Medicaid eligibility under the federal reconciliation law, which now limits matching funds to citizens, green card holders and a small group of other legal entrants. Montana's health department estimates about 50 people will lose coverage in the first month.

A system still being assembled

State health officials told lawmakers at a September 9 hearing that they plan to process roughly 5,000 enrollees a month and that they are "100% confident" they will be able to access the claims data the new medical-frailty standard depends on, according to the Helena Independent Record.

Other pieces are not in place. Of the 59 positions DPHHS said it would need, about 20 were filled as of that hearing, with officials citing turnover. A system to automatically verify enrollment at public universities is not expected to be running until next year, leaving students to assemble and submit documentation themselves.

In Missoula, substitute teacher and returning student Bethany Zulick told KFF Health News that a June letter left her "completely confused": it said she would have to prove compliance at her next renewal in the spring, then told her lower down to submit paperwork within 30 days of the letter's June 26 date. State Rep. SJ Howell said the office has fielded dozens of calls from constituents about the same notices. Health officials told lawmakers that the letters have since been revised.

Outside help has thinned. Cover Montana, a nonprofit that assists residents with benefit paperwork, lost federal funding last year and went from a staff of 18 to two part-time employees on a phone line. The state operates a helpline, but federal data shows Montanans wait on hold longer than the national average and that many callers hang up before reaching anyone.

"We were worried about chaos that could be generated by the state rushing," Aaron Wernham, chief executive of the Montana Healthcare Foundation, told KFF Health News. "Given how little information the state has provided about what they are doing, I'm much more worried about chaos."

Why treatment providers are watching

Montana's numbers are small next to the national stakes for addiction care. Medicaid covers nearly half of nonelderly adults with opioid use disorder, and it financed more than half of all medication for opioid use disorder nationally by 2023, as an Urban Institute analysis published September 22 documented.

The law's work requirements include narrow exemptions for people with substance use disorders, but the same analysis found that many eligible patients will struggle to produce the documentation needed to claim them. That concern is sharper in Montana, where enrollees are now being asked to prove medical frailty through provider attestation and claim history rather than their own statement.

For people on medication-assisted treatment, even a short gap in coverage can interrupt a buprenorphine or methadone prescription, and research cited in the Urban Institute analysis links coverage interruptions to an immediate rise in fatal overdose risk. People seeking care for opioid addiction can find treatment programs nationwide regardless of coverage status.

The last time states ran a mass eligibility review, the process itself became the story. During the 2023 unwinding that followed the pandemic-era pause on eligibility checks, roughly 87,000 Montanans who were financially eligible lost coverage for procedural reasons such as incorrectly completed paperwork, according to state data — including some people who should have been automatically renewed.

The national timeline behind the deadline

Most states must have work requirements operating by January 1, 2027. Modeling by the Urban Institute cited in the September analysis projects that the law's work requirements and six-month redetermination cycle for the expansion population could reduce Medicaid enrollment by 4.9 million to 10.1 million people in 2028, while the Center for American Progress estimates about 1.6 million people with substance use disorders would lose coverage.

Montana's own experience will be the first large-scale test of whether states can build the administrative machinery in time. The state said it plans to process roughly 5,000 enrollees monthly; critics note that the federal government gave states more than a year to prepare and Montana volunteered to move faster.

Montana House Democrats, including Rep. Mary Caferro, pushed earlier this year to delay implementation until the January 2027 deadline. That effort failed. The first compliance data from the October 1 rollout is expected to emerge in the coming months, when the state begins disenrolling people who do not respond.