H.R. 1 Impacts to Montana Medicaid Expansion

Access to health care is essential for the well-being of people in Montana and their ability to fully participate in their communities. All Montanans should be able to stay healthy and without preventable pain or illness. Changes to Medicaid Expansion by the federal bill known as “One Big Beautiful Bill” or “H.R.1.” could threaten access to health care for many Montanans. Many of these changes make applying for and navigating Medicaid Expansion more difficult, including additional paperwork, higher call volume, and longer wait times for assistance. These new regulations add barriers, compliance checks, and other challenges.

While H.R. 1 requires states to implement these new requirements by January 1, 2027, the Montana Department of Public Health and Human Services (DPHHS) stated it intends to implement these harmful requirements quicker. In September, DPHHS submitted an application called an “1115 Demonstration Waiver Application” to the federal government agency Centers for Medicare & Medicaid Services (CMS) requesting approval to implement H.R. 1 in 2026. CMS has indicated that it will not approve community engagement, or work reporting, requirements through the 1115 waiver process, and the state will have to submit a Medicaid state plan amendment to show how it will comply with H.R. 1. The state is aiming for a July 1, 2026, implementation date.

This blog provides an overview of the changes H.R. 1 makes to redetermination and work reporting requirements and exemptions that will impact the Medicaid Expansion population. In an upcoming post, we will highlight some of the ways DPHHS can reduce harm to Medicaid enrollees.

More Frequent Redeterminations

H.R. 1 changes the frequency of redeterminations from every 12 months to once every 6 months, and states must implement this change by January 1, 2027. American Indians are exempt from this change and will remain on an annual redetermination schedule. Redeterminations review whether people enrolled in the program are still eligible to receive benefits. The process may require enrollees to submit additional paperwork or other verification, creating additional barriers to recipients of Medicaid Expansion benefits. Six-month redetermination also means enrollees must meet community engagement requirements (below) in each six-month redetermination period.

Work Reporting Requirements

H.R. 1 creates community engagement requirements for people between the ages 19-64 receiving Medicaid Expansion which must be implemented by January 1, 2027. These are often described as ‘work requirements’ or ‘work reporting requirements’ and require individuals have 80 hours of allowable activities in a one-month period or be determined exempt. An individual with monthly income equal to or greater than $580/month (or seasonal worker with average monthly income over six months) will be considered compliant and exempt from reporting. Allowable activities include employment, job training, a minimum of half-time enrollment in an educational program, community service, or a combination of this list.

New work reporting requirements will impact both initial applications and redeterminations. A new enrollee must show compliance (or one of the below exemptions) for the 30 days prior to application. Once enrolled, H.R. 1 requires states to determine compliance or exemption for at least one month within the six-month redetermination period.

Exemptions

H.R. 1 also includes several mandatory exemptions that states are required to implement. The state is required to try and automatically process as many of these exemptions as it can without additional documentation; however, there will likely be additional paperwork burdens on many as these systems are built and issues are identified. Many exemptions do not work well with a 30-day look-back period, as some of the exemptions can be acute, or sudden, onset.

Below is the list of exemptions outlined in H.R. 1. Unfortunately, CMS has not provided much additional guidance on how states should define or implement the exemptions.

• parent, guardian, caretaker relative, or family caregiver of a dependent child age 13 or under or a disabled individual;

• American Indian or urban Indian, as defined under the Indian Health Care Improvement Act, or otherwise determined eligible for Indian Health Services;

• pregnant or accessing postpartum Medicaid coverage;

• foster youth or former foster youth under the age of 26;

• veteran with a disability rated as total;

• medically frail, including an individual who:

  • is Blind or disabled;

  • has a substance use disorder;

  • has a disabling mental disorder;

  • has a physical, intellectual, or developmental disability that significantly impairs their ability to perform 1 or more daily activities of daily living;

  • has a serious/complex medical condition.

• receiving TANF/SNAP benefits and in compliance with work requirements associated with those programs.

• participating in a drug addiction or alcohol treatment and rehab program; or

• currently or previously incarcerated in a public institution within a three-month period of application.

Communication Requirements:

Three months before the implementation of work-reporting requirements, the state must notify beneficiaries who are required to comply. On December 16, 2025, DPHHS stated its intention to begin communications and outreach prior to implementation but did not specify when that outreach would begin.  States must provide outreach by mail (or email if selected by beneficiary) and one or more other formats. This can include telephone, text, website, or other electronic means. DPHHS has provided little detail on its plans for outreach to enrollees.

States must include the timeline based on its implementation date (July 1, 2026, according to DPHHS statements), and states must include the number of months that the state requires documentation of community engagement. DPHHS indicated that they would use all the methods above except phone calls.

Most people on Medicaid Expansion in Montana are working or are exempt from these new rules. However, experience in other states with similar requirements shows that many individuals lose coverage due to the burdensome reporting requirements. As Montana works to implement these new federal requirements, the state needs to be careful, intentional, and prepared to ensure that it doesn’t needlessly remove eligible Montanans from Medicaid Expansion. In an upcoming post, we will highlight some of the ways DPHHS can reduce harm to Medicaid enrollees.