Helena advocates warn Medicaid work rules could threaten coverage

Helena advocates warned that Montana’s new Medicaid work rules could put coverage at risk for adults ages 19 to 64 in Lewis and Clark County, including people who already work but may miss a notice, a deadline or a documentation check.

The Montana Department of Public Health and Human Services says it will begin enforcing the community-engagement requirement on July 1, 2026, with mailed notices going to Medicaid members and eligibility reviewed at application and again every six months at renewal. Under the rule, non-exempt adults on Medicaid expansion must show 80 hours a month of approved work, volunteering, education, community service, internships, registered apprenticeships or workforce training.

The state’s published exemption list is broad, but it still leaves many people to prove they qualify. Exemptions include adults 65 and older, American Indians, pregnant and postpartum people, parents or caregivers of dependent children under 13, parents or caregivers of people with disabilities, Medicare-eligible people, medically frail individuals, veterans with total disability ratings, and some people who are currently or recently incarcerated.

That paperwork burden is exactly what worries local advocates. Denver Henderson of the American Cancer Society Cancer Action Network called the policy a “life-threatening direction” for Montana and said the system needed to process the new rules could strain the state’s technological and human resources. In a county like Lewis and Clark, where people often juggle multiple part-time jobs, patchy internet service and complicated family or health situations, advocates say the biggest threat may not be a lack of work but a missed form, an unanswered letter or a failed online report.

The concern reaches beyond one county. Montana Healthcare Foundation says Medicaid expansion covers more than 32,500 Montanans with at least one serious illness and about 16,500 people with serious mental illness or substance use disorder. The foundation has urged the state to strengthen in-person help, add helpline staff, improve data-sharing and train community organizations so patients do not lose coverage over preventable errors.

The debate in Helena also comes with history. Montana passed HB 658 in 2019 with similar 80-hour work and community-engagement language, along with gradually increasing premiums, but the state never won federal approval from the Centers for Medicare & Medicaid Services. State materials say the proposal stalled through 2020, and later court action in Arkansas underscored the risk of coverage losses when agencies fail to weigh administrative fallout.

That warning matters because the people targeted by the rule are not a small outlier. KFF says nearly two-thirds of Medicaid adults ages 19 to 64 were working in 2023, and research from Arkansas found confusion, reporting failures and coverage losses without a gain in employment. In Helena, that leaves the state with a stark test: whether the new system will connect people to work and care, or push eligible Montanans off coverage because the paperwork was too hard to keep up with.