Montana officially began implementing community engagement requirements for its Medicaid expansion program July 1, making the state one of the first in the nation to enforce the new rules, which stem from federal legislation signed into law last year.
The requirements, known formally as community engagement requirements, mandate that most adults between the ages of 19 and 64 enrolled in Medicaid expansion document at least 80 hours per month of qualifying activities — including paid work, education, job training, community service or volunteering — in order to maintain coverage. Montana chose to implement the requirements ahead of the federal deadline of January 1, 2027, positioning itself as a national early adopter alongside three other states.
The effort to add such requirements to Montana’s Medicaid expansion program dates back to 2019, when the state Legislature adopted similar language, but the state never received federal approval to enforce them. Last year’s federal reconciliation package, known as the One Big Beautiful Bill Act, mandated that all states with Medicaid expansion implement community engagement requirements by the end of 2026, giving Montana the federal authorization it needed to move forward.
The Montana Department of Public Health and Human Services said it is fully prepared for the transition, with trained staff, clear exemption processes and systems in place to support members. The department has been reaching out to Medicaid enrollees by mail since March to explain the requirements and encouraged members to update their contact information and check their eligibility status through the state’s online portal at apply.mt.gov.
Several groups are exempt from the requirements, including pregnant women, parents or caregivers of children under age 14, American Indians and people with health conditions that significantly impair their ability to work. The department updated its list of qualifying medical conditions the day before the July 1 launch, adding more than 50 diseases and conditions — including cancer, heart disease, Parkinson’s disease and disabling mental illnesses — as potential grounds for a medical exemption. Enrollees can self-attest under penalty of perjury that a condition prevents them from working, with attestations subject to later audit by the state.
DPHHS announced a three-month hold harmless period running through the end of September, during which people found out of compliance will be notified but will not immediately lose coverage. Beginning in October, noncompliance will be enforced, with disenrollment possible for those who fail to meet the requirements.
During a recent interim legislative committee meeting, DPHHS officials told lawmakers the department can already verify some eligibility data automatically — for example, confirming American Indian status or cross-referencing compliance with work requirements for other benefit programs such as SNAP or TANF. Officials said they hope to expand automatic verification to additional categories in the future.
As of March, roughly 73,895 adults were enrolled in Montana’s Medicaid expansion program. The state’s own estimates projected that approximately 13,000 adults could lose coverage over the next two years as a result of the new requirements, including some who are technically eligible but may struggle with the documentation process.
Health care advocates and some providers have raised concerns about the rollout, pointing to Montana’s processing times for Medicaid applications — which as of March ranked among the worst in the nation, with 35% of applications processed beyond the required 45-day window — and call abandonment rates that ranked second worst nationally at 40%. Advocates said many people who qualify for exemptions or meet the work requirements could still lose coverage due to paperwork challenges and difficulty reaching the department.