Montana Enforces Medicaid Work Rules, Patients Confused

Montana on October 1 became one of the first states in the nation to enforce new Medicaid work requirements, ending a three-month grace period that gave roughly 71,000 low-income adults until the deadline to document their compliance or claim an exemption. The enforcement date arrives three months ahead of the federal January 1, 2027 deadline — and nine months after the state’s July 1 soft launch, which itself began six months early — leaving many enrollees confused about whether they still qualify for coverage, according to NPR.

What the New Rules Require

Under the requirements mandated by the federal One Big Beautiful Bill Act, signed into law in July 2025, enrollees ages 19 to 64 in Montana’s Medicaid expansion population must document 80 hours per month of work, volunteering, studying, or job training — or qualify for an exemption. Qualifying exemptions include being “medically frail,” serving as the primary caretaker for a family member, being pregnant or postpartum, being Native American, or facing a short-term hardship.

The rules apply to nearly 71,000 Montanans, and noncompliant enrollees can be removed from the rolls after receiving notice and a 30-day window to respond. Most states must implement similar requirements by January 1, 2027, but only Montana, Nebraska, and Arkansas have started early, according to KFF.

Confusion From the Start

The early rollout has been marked by communications problems. Bethany Zulick, a Missoula resident who returned to school to become a high school English teacher and relied on Medicaid for coverage, received a June letter that she said left her “completely confused.” One section stated her compliance would be verified at her next renewal in spring 2027; another, lower down, said she had to submit paperwork within 30 days of the June 26 letter date.

“The notices coming from the department are very, very confusing, and it’s very hard to find help figuring out what’s going on,” state Rep. SJ Howell, a Democrat, told KFF Health News and Montana Public Radio. State health officials said at a September 9 legislative hearing that the letters have since been updated.

The state has also struggled to build the infrastructure needed to run the program. Of the 59 positions the health department said it needed, only about 20 were filled as of the September hearing, with officials citing turnover. A computer system to automatically verify student enrollment at public universities is not expected to be operational until 2027.

Outside help is scarce, too. Cover Montana, a nonprofit that assists residents with Medicaid paperwork, lost federal funding and shrank from 18 staff members to two part-time employees running a phone line. Federal data shows Montanans wait on hold far longer than the national average to reach the state’s helpline, with many callers hanging up before connecting with an employee, per Georgetown University’s Center for Children and Families.

Warnings of Repeat Disruption

Critics point to the state’s 2023 post-pandemic eligibility review as a cautionary precedent. During that process, roughly 87,000 Montanans — many of whom were financially eligible — lost coverage for procedural reasons such as paperwork errors, and even some who should have been automatically renewed were dropped, including homeless residents.

“We were worried about chaos that could be generated by the state rushing,” said Aaron Wernham, CEO of the Montana Healthcare Foundation. “Given how little information the state has provided about what they are doing, I’m much more worried about chaos,” Wernham told Montana Public Radio in July.

The concerns extend to the state’s finances. Montana is simultaneously managing a $183 million Medicaid shortfall and a dispute over a 3% provider rate increase, a dynamic that KFF Health News reported earlier this year could stress-test the federal work rules.

A National Preview

Because the early-adopting states are moving without fully built verification systems, their experience is being closely watched as a preview of the national rollout. Analysts warn that states may still lack automated verification systems by the federal deadline, pushing manual, case-by-case processing that risks backlogs and further coverage loss, Healthcare Dive reported.

“The handful of states that are implementing the Medicaid work requirements early are building the plane as they’re taking off,” Akeiisa Coleman, a Medicaid analyst, told NPR. “Montana is going to be an example for what we might see nationally as things roll out.”

Nebraska launched its requirements first, on May 1, 2026, and Arkansas soft-launched on July 1 alongside Montana, Healthcare Dive reported. Arkansas’s earlier, 2016-era work requirement experiment saw more than 18,000 people lose coverage before courts blocked it.

State officials insist they are ready. Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, said the agency is committed to ensuring eligible Montanans maintain coverage while meeting the requirements. Health department leaders have also said they have no plans to extend the October 1 deadline despite repeated requests from Democratic lawmakers.

Supporters of the requirements argue the rules promote accountability. “In an economy like this, if you’re an able-bodied adult that’s able to work, you really do need to step up,” Montana Senate President Matt Regier, a Republican, said. Asked about the confusion, Regier said the October 1 deadline offered more than enough time to work out the kinks.

What to Watch

As enforcement begins, the central question is how many Montanans will actually lose coverage — and how many will be dropped not because they are ineligible, but because they failed to navigate the paperwork in time. Montana’s experience over the coming months is likely to shape how other states approach their own January 1 deadlines, and whether calls grow for federal guidance on exemptions and automated verification.

For enrollees like Heather Reel, who relies on Medicaid for mental health coverage while caring for a nonverbal teenage son with autism, the stakes are immediate. Between shifts at a fast-food restaurant and caregiving, she said she fears she will be too busy to figure out how to report her work hours.