Montana is preparing to implement new federal work (also called “community engagement”) requirements in July for adults enrolled in Medicaid. Last month, we released an issue brief outlining steps the state can take to minimize coverage loss among people who meet the new requirements or are exempt from them by law.

We have been studying Montana’s Medicaid program for the past decade. In particular, we’ve looked at Medicaid expansion, which was implemented under the HELP Act in 2016 and made a permanent part of Medicaid in 2026. The people covered under Medicaid expansion include adults who make up to 138% of the federal poverty level (roughly $20,000 a year). Over this time, our analyses have found:

• When people have health insurance, they use it. They go to their primary care doctor, they get cancer screenings, they get support for their mental health, and they go to the dentist. They need fewer expensive ER visits because they can afford to get their health needs taken care of before small problems become emergencies.
• Of the approximately 75,000 adults currently enrolled in the Medicaid expansion group, an estimated 72% are working or attending school. An additional 23% are caregivers or disabled, leaving only 6% of people (or around 4,500) who are not in the labor force and do not fall into any other category.
• Medicaid expansion provides health coverage for Montanans with serious physical and behavioral health needs. Of those covered, an estimated 32,500 have cancer, heart disease, or diabetes; another 16,500 have serious mental illness or substance use disorders.

The Montana Department of Public Health and Human Services (DPHHS) plans to implement new federal work requirements beginning in July for people enrolled in Medicaid expansion. Under the new requirements, enrollees must either work, attend school, or participate in community service. Many people are exempt from these requirements, including people with substance use disorders, serious mental health conditions, serious or complex medical conditions, various types of disabilities and activity limitations, and those who are American Indian or Alaska Native, caregivers, or meet other exemptions defined in the new federal law.

Implementing these new requirements accurately will be a substantial undertaking for DPHHS. By law, DPHHS must use available data to determine whether each current enrollee is meeting the new requirements or is exempt from them. Montana faced a related challenge in 2023, when states had to redetermine Medicaid eligibility following the end of the pandemic. Roughly 90,000 Montanans lost Medicaid coverage; of those, nearly two-thirds were not actually found to be ineligible but instead lost coverage for various procedural reasons.

We looked across the country and compiled a list of best practices that Montana can implement to keep eligible Montanans from losing their health insurance. They include:

1. Assess medical frailty carefully by developing a rigorous definition, leveraging claims and health information exchange data at renewal, and providing a user-friendly screening tool at application.
2. Maximize the use of available databases and automated systems to support federal compliance and identify enrollees who are exempt from the new requirements.
3. Enhance state capacity to assist applicants and determine eligibility by training existing staff on new systems and hiring additional staff to support implementation.
4. Use clear, consumer-friendly applications, renewal forms, and notices to reduce confusion among Medicaid members.
5. Support outreach and engagement with trusted community partners, including providers, community-based organizations, and tribal entities, to ensure members understand new requirements and how to meet them.
6. Monitor outcomes, ensure transparency, and course correct early, using timely data to identify unexpected disenrollments and adjust processes to mitigate further impact.

The landscape is also shifting for Montana’s rural health care providers. Beyond the importance to individuals, Medicaid is a source of reimbursement that helps keep health care available in rural communities. We hope that these recommendations provide a roadmap for Montana that helps its rural hospitals keep their doors open and continue providing services that entire communities depend on.