Montana says failure to meet its Medicaid work rules may lead to denial or loss of coverage starting Oct. 1. Its early rollout has already brought a confusing notice, staffing gaps and reduced help for people navigating the rules. The risk is that eligible people could lose health coverage because they cannot understand or document what the state requires, not because they refuse to work.
That distinction is partly in states’ hands. Federal rules give them flexibility in verifying whether a health condition excuses someone from the work requirement. At least six states are choosing to demand documentation sooner than federal rules require. Supporters of stricter checks argue that accepting people’s statements risks fraud; the test is whether eligible people can prove their circumstances without getting caught in a paperwork trap.
What the Medicaid work requirement demands
The federal law applies to certain adults covered through Medicaid expansion, not everyone on Medicaid. Those subject to it generally must complete 80 hours a month of work, volunteering or another qualifying activity, or attend school at least half-time. People in specified circumstances, including those who qualify as medically frail, can be excused from the activity requirement.
States must begin applying the condition by Jan. 1, 2027, unless they start earlier. Nebraska began implementing it in May. Montana began July 1, while Arkansas started a soft rollout that does not disenroll people before January 2027. Iowa plans to start in December. Early states are putting their systems to use while others still have time to prepare.
The potential reach is substantial, but it is not a count of people who have lost coverage. The Associated Press reported that the requirement could affect up to 20 million adults without children at home across 40 states and the District of Columbia. It does not apply in the 10 states that have not expanded Medicaid.
The Centers for Medicare & Medicaid Services says employment, education and volunteering can promote self-sufficiency. Montana Senate President Matt Regier supports the requirement as a matter of accountability for adults able to work. Those arguments describe what the policy aims to encourage. They do not establish whether a state can reliably distinguish someone who failed to meet the rule from someone who met it, qualifies for an exception or cannot get a clear answer about either.
Where states are making medical exceptions harder to prove
Medical frailty shows how an implementation choice can change an enrollee’s path to keeping coverage. Federal guidance says states should first try to verify a qualifying condition through reliable information they already have, such as health claims and other records. The condition must significantly impair the person’s ability to comply with the activity requirement; a diagnosis alone does not necessarily answer that question.
Before Jan. 1, 2028, federal guidance allows states either to require documentation or to accept a person’s statement under penalty of perjury when determining medical frailty. Beginning in 2028, the guidance limits repeated self-declaration. Once frailty has been verified through reliable information or documentation, states must check it again at least annually.
Arkansas, Idaho, Indiana, New Hampshire, North Carolina and Ohio have laws or policies barring self-attestation for this exception starting in 2027, the Associated Press reported. Those are state choices, not an immediate federal ban on accepting a person’s account of their condition.
The strongest case for requiring documents is that an exception should be verifiable. Jonathan Ingram, vice president of research and policy at the Foundation for Government Accountability, opposes relying on beneficiaries’ statements because he sees a risk of fraud. A state responsible for public funds has reason to check eligibility. But requiring provider paperwork can put a hurdle before someone seeking Medicaid because health care is already hard to afford. Jennifer Tolbert, KFF’s director of state health policy and data, has warned that applicants may not be able to pay for a doctor’s visit before they have coverage.
Existing records will not always settle the question, either. Lucy Dagneau of the American Cancer Society Cancer Action Network has warned that diagnosis codes may not show how severely an illness limits a particular person’s capacity to work. When available data are incomplete, a stricter documentation rule shifts the burden onto the applicant to find more evidence. Whether that prevents improper exemptions or blocks eligible people depends on how each state handles those cases.
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Montana’s notices and staffing put the deadline to the test
Montana’s rules cover Medicaid expansion adults ages 19 to 64 who do not qualify for an exclusion. The state accepts activities including work, volunteering, approved workforce training, internships, apprenticeships and half-time schooling. Nearly 71,000 enrollees were reported to be subject to the new rules.
Montana began implementation July 1 but set a period through September during which noncompliance would not trigger a loss of coverage. Starting Oct. 1, the state says noncompliance may lead to denial or disenrollment. That change makes clear instructions about deadlines and proof especially consequential.
One enrollee said a notice she received gave conflicting information about when proof was due. State health officials told lawmakers they had revised notices to make them clearer. Montana Rep. SJ Howell told KFF Health News: “The notices coming from the department are very, very confusing, and it’s very hard to find help figuring out what’s going on”.
Help was also harder to find outside the state agency. KFF Health News reported that Cover Montana, a nonprofit that assists residents with paperwork, went from 18 staff members to two part-time employees answering a phone line after losing federal funding the previous year. Federal data cited by the outlet showed Montana callers waited longer than the national average on the state helpline, and many hung up before reaching an employee.
Officials told lawmakers they expected to process about 5,000 enrollees a month. At a Sept. 9 hearing, they said about 20 of 59 planned positions were filled, with staffing fluctuating because of turnover. Those figures do not show how many cases will be decided correctly. They do show why the state’s ability to explain notices, answer calls and review evidence matters alongside the rule itself.
Montana’s health department says it is prepared for the change and has no plans to extend the deadline, despite requests from Democratic lawmakers. Spokesperson Jon Ebelt told KFF Health News: “We are committed to ensuring eligible Montanans maintain coverage while meeting requirements, and we will continue to monitor implementation closely”.
The coverage losses that have not yet been counted
Montana’s past offers a warning, not a result of the new work rules. During the state’s 2023 Medicaid eligibility review, about 87,000 people lost coverage for technical reasons, according to state data cited by KFF Health News. That was a different process. It helps explain advocates’ focus on the difference between being ineligible and losing coverage because paperwork was not completed or processed as intended.
A national estimate needs the same distinction. The Congressional Budget Office projected in 2025 that the federal Medicaid changes would reduce spending by $887 billion over a decade and leave 7.5 million fewer people with health insurance, the Associated Press reported. That projection covers the Medicaid changes overall; it is neither a count of losses so far nor a forecast attributable solely to these work requirements.
The immediate measure of Montana’s rollout is narrower: how many people retain coverage, how many are denied or disenrolled under the work rule, and whether those decisions reflect eligibility rather than unresolved notices or missing documentation. With the state’s hold-harmless period ending Sept. 30, its handling of those cases will put its promise to preserve eligible people’s coverage to a practical test.
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