Montana DPHHS moving forward with July 1 work requirement start date despite questions

Carly Graf Missoulian Jun 9, 2026

Advocates were already concerned about the state health department’s plan to implement Medicaid work requirements six months ahead of the federal deadline, but rules released last week by the Trump administration have intensified their fears.

As Medicaid recipients brace for new work requirements to upend their access to the system, advocates are closely watching how bureaucratic trip-ups could worsen their chances at staying enrolled. In particular, people with a serious medical condition, disabling mental disorder or substance use disorder could have a harder time proving that they should be exempt from the mandate that they work or attend school 80 hours each month.

According to the federal rules package, a person can’t just be diagnosed with a condition that qualifies them as “medically frail.” They must also prove that they are unable to work because of their diagnosis. How someone demonstrates their medical condition impairs their employment is not specified by the Trump administration — that task falls to the states.

Charlie Brereton, the director of the Montana Department of Public Health and Human Services, said the federal rules have no effect on the state’s implementation timeline; as of Monday, the DPHHS website said it was “still in the process of defining ‘medically frail’ in relation to this program, and no final decisions have been made.”

With less than a month until work requirements start to hit Medicaid enrollees in Montana, healthcare advocates said they are unclear on how DPHHS will deal with the latest snag, especially given what’s already an accelerated rollout.

“This is a pretty significant shift in how states will be handling the exemption for medical frailty,” said Heather O’Loughlin, the director of the Montana Budget and Policy Center. “I think the big question is how the state is planning to respond to what is nearly 400 pages in federal rules being released a month from when they continue to say they plan to implement.”

DPHHS estimates that around 13,000 adults, or about 18% of the Medicaid expansion population, will lose Medicaid coverage because they are not meeting the community engagement mandate. There were 207,902 people enrolled in Medicaid as of March, the last enrollment tally the state made public. Of those, 73,895 adults are enrolled in Medicaid expansion, the income-based program and will be subject to work requirements; however, some have cautioned that everyone will be affected by a bogged down system.

Individuals on Medicaid deemed “medically frail” were supposed to be exempt from the work requirements and state agencies were expected to be able to automatically confirm a person’s status under that exemption using information gathered from insurance claims.

However, this new definition of medical frailty that ties a person’s diagnosis to their ability to work means that states will likely have to create entirely new systems to determine eligibility. That means more paperwork, more confusion and, according to skeptics, more people getting kicked off healthcare because they can’t navigate the bureaucracy.

“The reality is that there will be fewer individuals who will likely qualify for this exception,” O’Loughlin said. “It inserts a lot of uncertainty about how the state will communicate this exemption and how an individual can document that they face a serious health condition. It’s this very population that is now at risk of losing healthcare coverage while facing serious health needs.”

The change, which will go into effect after the work requirements have started to be applied to new and existing Medicaid patients, could ensnare cancer patients who can’t hold a steady job because of frequent treatment appointments. Someone with multiple sclerosis might experience debilitating flare-ups, though not often enough to get a doctor to say they can't work.

“What’s sick enough?” said Aaron Wernham, the executive director of the Montana Healthcare Foundation. “Thousands of people with serious and even life-threatening illnesses could lose coverage unless Montana develops a good system to figure out who should be excluded because they are medically frail.”

Exactly how many people might be eligible for a medical frailty exemption is unclear. One estimate from the Montana Healthcare Foundation found that in 2024 around 16,500 people had a serious mental illness or substance use disorder, and 1,805 had a cancer diagnosis.

Brereton said in a statement that DPHHS is “fully committed to protecting Medicaid for vulnerable Montanans and is also fully prepared to implement community engagement requirements for Medicaid Expansion members effective July 1.” Still, Montana’s track record during the post-pandemic Medicaid unwinding era has many skeptical that the department can really bend and not break under the influx of paperwork coming its way.

DPHHS was one of the slowest in the country to process income-based applications during that time, and thousands of people lost healthcare coverage due to procedural errors not ineligibility. As of April, DPHHS still had one of the longest average wait times on the phone help line in the country, and approved fewer renewal applications automatically than the national average.

The department is in the process of hiring 60 additional administrative positions to handle the increased workload, though not all of those positions have been filled.