MBPC’s Comment on the 1115 Waiver Amendment

Last week, Montana Budget & Policy Center submitted our comments in relation to the proposed amendment to Montana’s 1115 demonstration waiver for the Health & Economic Livelihood Partnership (HELP) program, as well as, the proposed 1115 demonstration waiver for Montana’s basic Medicaid program (which DPHHS has referred to as the Waiver for Additional Services and Populations, or WASP).

As one of several organizations working to expand Medicaid in Montana, MBPC supported the Health and Economic Livelihood Partnership (HELP) Act, passed by the Montana Legislature during the 64th Legislative Session. As of July 1, 2021, over 100,000 low-income Montanans were enrolled in affordable health care coverage. This effort has moved Montana closer toward closing the coverage gap, has reduced uncompensated care, and has injected billions in taxpayer dollars into our local economies. MBPC urges the Department to consider the impact that more frequent determinations will have on Montanans. Twelve-month continuous eligibility has proved to be a success in Montana..

To read our submitted comments, download the PDF here.

Medicaid Provides Stability for Montanans During Times of Crisis

During the stay-at-home order, Medicaid provided an important safety net to thousands of laid-off workers. Montanans on Medicaid expansion were more likely to lose their jobs during the early weeks of the COVID-19 pandemic, according to a recently released study by the Montana Departments of Labor and Industry, Revenue, and Public Health and Human Services. Without Medicaid expansion, thousands of Montana workers would have faced a dual tragedy of losing not only their jobs but also their health care in the midst of a public health crisis.

Medicaid Expansion Helps Workers During Times of Crisis

In 2015, Montana passed the Health and Economic Livelihood Partnership (HELP) Act, which expanded Medicaid coverage to individuals whose incomes are less than 138 percent of the federal poverty level (or less than $17,608 for an individual).[1],[2] As of October 2020, 89,299 Montanans (8.4 percent of the state’s population) participated in the program.[3] About 9 in 10 of those enrolled in Medicaid expansion are living below the poverty line, and one in five are American Indian.[4],[5] Medicaid expansion has played a critical role in rural Montana, with roughly half of enrollees residing in rural communities.[6]


Since the pandemic took shape in March 2020, Medicaid expansion enrollment has grown by 7,848. This expansion has helped Montanans living on low incomes avoid financial insecurity and difficulty accessing affordable health care. While Medicaid enrollment has risen across the country, Montana’s remains lower than its peak in 2018.[7],[8]

Supporting Thousands of Workers Who Lost Jobs

On March 26, Gov. Steve Bullock issued a shelter-in-place order, closing non-essential businesses and operations to help control the spread of the novel coronavirus.[9] During the month of April, unemployment in Montana reached 11.9 percent, three times higher than it had been in February. In April of 2019, unemployment was at 3.5 percent.[10]

Workers receiving Medicaid expansion were more likely than other workers to lose their jobs in the early weeks of the COVID-19 pandemic.[11] The shutdown disproportionately affected those working in customer-facing jobs, such as retail and food service. These industries are also among the lowest-paying industries for average annual wage in Montana and thus have high numbers of workers on Medicaid expansion.

Despite representing 12 percent of the workforce, workers on Medicaid expansion accounted for 19 percent of the unemployment claims filed in the peak week of April 18. At this point in April, the height of the unemployment crisis, 18,700 people were simultaneously on Medicaid expansion and unemployment insurance. The vast majority of these workers – 82 percent – had been employed prior to March and had not been receiving unemployment insurance.

As more workers lost their jobs over the summer, Medicaid expansion provided an important safety net for those who had not previously needed the program. Roughly 3,400 workers, who had not been receiving unemployment or Medicaid, enrolled in both programs between March 1 and July 25. During this time of severe need, Medicaid did what it was designed to do: it provided people in crisis with access to health care.

At a time of uncertainty and rapidly rising unemployment, Medicaid expansion helped provide stability for workers facing sudden job losses. Prior to the COVID-19 crisis, Medicaid expansion was already helping adults with jobs that pay inadequate wages – most of who were working full-time.[12]

Nationwide, jobs in low-paying industries bore the brunt of pandemic-related job loss and have been slow to recover. Between February and September 2020, jobs in low-wage industries were down twice as much as jobs in medium-wage industries (11.5 percent vs. 6.9 percent, respectively) and almost three times as much as in high-wage industries (4.1 percent.)[13]

Supporting Businesses During Reopening

While unemployment remains high for many adults with low incomes, many Montana businesses have re-opened. Medicaid expansion provides support for essential workers whose jobs involve increased health risks. As Montana sees rising case numbers, ensuring all Montanans have access to affordable health care has never been more important.

Workers in the most common low-wage occupations – including salespersons, wait staff, janitorial staff, and teaching assistants – work in jobs that cannot be performed remotely and often face frequent contact with the public.[14] These industries also commonly hire part-time staff and are less likely to offer employer-sponsored health insurance.

In Montana, 89 percent of businesses in the accommodation and food service sector and 70 percent of businesses in the retail trade sector employ workers on Medicaid expansion. Perhaps most critically, two-thirds of health-care businesses in Montana also employ workers on Medicaid expansion.[15] Health-care workers who are in frequent, close contact with patients, such as nurses’ aides, housekeeping, and janitorial support staff, face substantial health risks while performing their job.[16]

Helping Mitigate Health Inequities Due to Poverty

Not only do a disproportionate number of workers on Medicaid expansion face greater exposure to the virus due to the nature of their jobs, many workers living on low wages face poorer overall health. Several factors contribute to this, including high rates of stress, a lack of ability to access affordable care, difficulty affording healthy food, and living in disadvantaged communities that do not have safe housing or healthy environments.[17] Medicaid expansion allows beneficiaries to receive health care for conditions that may put them at a greater risk for serious illness from the novel coronavirus.

Certain medical conditions, including chronic obstructive pulmonary disease, uncontrolled asthma, or diabetes, put patients at greater risk for negative outcomes.[18] Over 35 percent of adults with incomes less than $15,000 are at a higher risk for serious illness due to factors such as these. Only 16 percent of those with incomes greater than $50,000 face similar health challenges.[19]

Since 2016, Medicaid expansion has provided 122,649 adults in Montana with preventive services, including for conditions which may cause critical cases of COVID-19. More than 5,500 adults have been diagnosed and received treatment for hypertension, and more than 2,400 adults have been diagnosed with and received treatment for diabetes.[20] Medicaid expansion not only allows beneficiaries to receive treatment for COVID-19, it also allows for treatment of underlying health conditions that may cause severe cases of the disease.

Supporting Tribal Nations

Recent studies show that American Indians are at higher risk of COVID-19 than any other racial or ethnic group, largely due to barriers to health-care services that result in higher rates of underlying health and economic conditions. Thirty-five percent of American Indians in Montana lack access to a primary health-care provider, compared to 26 percent of whites.[21] This lack of access to health services, coupled with generations of historical trauma and the United States’ failure to meet treaty obligations, has resulted in higher rates of asthma, diabetes, and heart disease for American Indians. [22] Many tribal nations in the U.S. are seeing greater spread of COVID-19 and have fewer resources to address it.[23]

Coronavirus has hit tribal nations in Montana especially hard. While American Indians comprise 7 percent of the state’s population, they account for 16 percent of cases. The outcomes are also far worse for American Indians: statewide, American Indians account for 28 percent of deaths for whom race is known.[24]

Medicaid expansion provides an important service in Indian Country. Nearly 17 percent of Medicaid expansion enrollees are American Indian.[25] Unemployment skyrocketed on reservations in April during the stay-at-home order, with rates as high as 22 percent on the Rocky Boy’s Reservation and 18 percent on the Northern Cheyenne Reservation.[26] Without continued access to affordable health-care coverage, individuals who lost their jobs would have faced compounded financial hardship.

Access to health care has improved for American Indians living in Montana due to the expansion of Medicaid. For tribal citizens living in urban areas, Medicaid expansion has increased options for medical care. Instead of being limited to Indian Health Service (IHS) facilities, American Indians can access any provider that accepts Medicaid.[27] Expansion has also improved the services offered. IHS has been able to increase services at all five locations in Montana and can now offer preventive services, such as cancer screenings.[28]

Medicaid Expansion Is Essential During Crises

The underlying inequities that have brought disproportionate harm to some communities will remain even as others recover from COVID-19 and the recession. People living on low incomes have weathered higher rates of job loss and faced greater risk from the virus itself. Medicaid expansion has provided a degree of stability for those impacted, allowing individuals to retain their access to health care, despite lost jobs. Without access to affordable health-care coverage, the pandemic would worsen financial hardship and health disparities among Montanans living on low incomes. As Montana faces the year ahead, ensuring all Montanans have quality health care is essential to the state’s recovery and efforts to build a better and more resilient home for everyone.

Montana Counties Benefit from Medicaid Expansion

MPBC Announces New Project – Big Sky Brighter Future

Today the Montana Budget & Policy Center announced its new project – Big Sky Brighter Future – a bold agenda providing policymakers with a clear course to prioritize Montana’s families and children as we rebuild our state.

Montana is a place we love to call home. Natural beauty and commitment to community make Montana an extraordinary place to live for many. However, many Montanans face barriers to building the best futures for themselves and their families, and the COVID-19 pandemic has laid bare discrimination in the very programs and systems meant to support workers and families.

To move Montana forward and truly make it a state where we can all live, work, and enjoy all that Big Sky Country has to offer, we must be bold. We need to rebuild our systems and eliminate structural barriers so that we all have what we need. Not just during times of crisis, but every day.

Big Sky Brighter Future includes 35 forward-thinking policies to point Montana toward a brighter future. We developed this plan with an eye toward equity for Montanans who are Black, Indigenous, and people of color. MBPC met with nonprofit organizations, advocates, and experts to develop a plan that includes policies to strengthen families, boost workers, educate for our future, and build resilient communities. Policies, such as investments in early childhood education, support for tribal health services, and paid sick days, are needed now more than ever. You can read the full plan here.

Big Sky Brighter Future also provides a down payment to pay for these policies with ten common-sense proposals that create a tax code that will work for everyone and bring in $241 million in new revenue.

Over the next few months and leading to the 2021 legislative session, we will work with partners, advocates, and families to make sure candidates running for office hear what our state needs. With your help, we can build the support to make this plan a reality.

We hope you will join us by reading our plan on our website at bigskybrighterfuture.org and following us on Facebook, Twitter, and Instagram. You can also sign up to learn more, start conversations in your community, and submit letters to the editor.

Big Sky Brighter Future is charting a clear course with concrete policy solutions to rebuild our state.

There’s a better Montana on the horizon, and we know how to get there.

Community Health Aide Program: Frequently Asked Questions

During the 2019 legislative session, the Montana Legislature passed House Bill (HB) 599, which allows community health aides to provide care under the Indian Health Service Community Health Aide Program in Montana. While there is still uncertainty around what CHAP and its implementation could look like in Montana, this report answers some frequently asked questions about the program.

What Is the Community Health Aide Program (CHAP), and Why Is it Important?

The Indian Health Service (IHS) established the Community Health Aide Program (CHAP) in rural Alaska in 1968 to increase access to quality health care in rural communities and Indian Country. CHAP does this by providing authority for mid-level behavioral, community, and dental health professionals, like community health aides, to work alongside licensed providers.[1]

In 2010, the U.S. Congress amended the Indian Health Care Improvement Act (IHCIA) to authorize the expansion of CHAP beyond Alaska.[2] The expansion of CHAP in Montana will increase opportunities to access health care across Indian Country. Nearly two-thirds of Montanans who are American Indian live in medically underserved counties, and Montanans who are American Indian are more likely than Montanans who are non-Indian to report barriers to accessing care.[3] Lack of access to care contributes to the lower health outcomes of Montanans who are American Indian, as compared to Montanans who are non-Indian, including a life expectancy that is, on average, 16 years shorter.[4] It is clear that Indian Country needs greater access to health care.

What Is the Indian Health Care Improvement Act (IHCIA)?

In 1976, the U.S. Congress passed the Indian Health Care Improvement Act (IHCIA), which provides the foundational legal authority for the provision of health care to American Indians and Alaska Natives.[5] Through the IHCIA, the U.S. Congress declared that it is the policy of the United States to fulfill its trust responsibilities and legal obligations to American Indians to:

  1. Ensure the highest possible health status for American Indians and to provide all resources necessary;
  2. Raise the health status of American Indians; and
  3. Ensure maximum American Indian participation in health care services, among other things.[6]

This trust responsibility stems from the fact that, between 1778 and 1871, the United States negotiated nearly 400 treaties with tribal nations.[7] Through these treaties, tribal nations ceded control of millions of acres of their homelands to the United States.[8] In exchange for land, treaties created a legal obligation for the federal government to provide services like health care.[9]

The IHCIA also amended the Social Security Act of 1935 to allow reimbursement by Medicare and Medicaid for services American Indians and Alaska Natives receive in IHS and tribal health care facilities. This amendment made Medicaid and Medicare services more accessible to more people, particularly for those residing in remote and rural locations, where Medicaid and Medicare providers may not be located.[10] The IHCIA also provided states with a 100 percent federal reimbursement for Medicaid services provided through an IHS or tribal facility, meaning the state Medicaid program incurs no cost.[11]

In 2010, President Obama permanently extended the IHCIA when he signed the Patient Protection and Affordable Care Act into law.[12]

If CHAP Is a Federal Program, Why Did the Montana Legislature Pass HB 599?

The IHCIA requires state authorization for specific types of aides, like dental health aides.[13]

How Are CHAP Activities Funded?

CHAP requires a separate federal appropriation within the IHS budget. At this time, Congress has not funded CHAP expansion activities.[14] However, the state and tribal nations can provide resources once the federal Secretary of Health and Human Services has certified the program. Further, HB 599 amended the Montana Medicaid program to include services provided by a community health aide and directs the Montana Department of Public Health and Human Services to apply for a state Medicaid plan amendment through the federal Centers for Medicare and Medicaid Services.[15]

What Is a Community Health Aide, and What Type of Health Aides Are Included in the Montana CHAP?

A community health aide is a mid-level, community-based health-care provider. HB 599 specifies that, once certified, individuals may practice in the areas of dental health, behavioral health, and community health.[16] While the certification board (more below) will ultimately determine the scope of practice for each type of aide for each of the practice areas, this section gives examples of care that aides in the Montana CHAP could potentially provide.

Dental Health

Dental health aides provide a range of services, depending on their level of training and certification. Types of dental health aides included in the Montana CHAP are primary dental health aides, expanded function dental health aides, dental health aide hygienists, and Dental Health Aide Therapists (DHATs).[17]

Primary dental health aides largely provide oral health promotion and oral disease prevention education.[18] Expanded function dental health aides and dental health aide hygienists provide progressively more advanced care, such as dental cleanings. DHATs, which require the most advanced level of training, can typically provide some restorative care and can perform some basic dental surgery procedures.[19] However, HB 599 prohibits individuals from performing dental extractions or invasive procedures to teeth and gums.[20]

Behavioral Health

Depending on their level of training and certification, behavioral health aides provide a range of services, including assisting with case management, patient and community education, patient evaluation, treatment planning, and treatment activities. Types of behavioral health aides included in the Montana CHAP are behavioral health aides and behavioral health practitioners.

Behavioral health practitioners may, only under the general supervision of a licensed behavioral health professional, conduct routine screening, assessment, evaluation, and counseling of patients.[21] Behavioral health practitioners require a more advanced level of training than do behavioral health aides.

According to the IHS CHAP expansion timeline, no other state outside of Alaska has yet to expand the use of behavioral health services.[22]

Community Health

Community health aides are mid-level medical providers who can provide basic medical attention and clinical care. Depending on their level of training and certification, community health aides provide a range of services, including family planning, health education, and maternal and child health.[23] Types of community health aides included in the Montana CHAP are community health aides and community health practitioners. Community health practitioners require a more advanced level of training than do community health aides.

According to the IHS CHAP expansion timeline, no other state outside of Alaska has yet to expand the use of community health services.[24]

Who Has Certification Authority Over CHAP?

The federal Secretary of Health and Human Services, acting through IHS, establishes and maintains a CHAP certification board, which adopts certification standards for individuals to act as specific aides within the program, including those standards related to scope of practice, training, supervision, and continuing education.[25] While there is not yet a national certification board in place, the certification board could be comprised of medical, dental, and behavioral health professionals. Additionally, because the Alaska CHAP currently has its own area certification board, it is likely that the Montana CHAP will also require an area certification board.

Certification boards require community health aides to have successfully completed training that demonstrates their capacity to provide care.[26] HB 599 specifies that individuals may practice in a setting operated by IHS or a tribal health program, as long as the individual is certified by either a federal CHAP certification board or a federally recognized tribal nation that has adopted certification standards that meet or exceed the requirements of a federal CHAP certification board.[27]

How Is CHAP Different from the Community Health Representatives (CHR) Program?

Both CHAP and the CHR Program are IHS programs; however, they have key differences. First, they have different scopes of work. Community health aides are mid-level medical providers who can provide basic medical attention and clinical care, such as inserting stitches.[28] Community health representatives, on the other hand, provide health promotion and outreach to community members.[29] They do not provide clinical care.[30] Examples of activities performed by community health representatives include providing patients with transportation to health appointments, informal counseling, and social support.[31]

Second, they have different funding sources. The CHR Program receives its own designated funding.[32] CHAP requires federal appropriations. At this time, CHAP expansion activities are unfunded; however, IHS plans to work with tribal nations to develop the budget.[33]

How Does CHAP Expansion Impact Tribal Health Programs, Services, Functions, and Activities (PSFAs)?

It depends upon whether a tribal nation has contracted or compacted with IHS.

When contracting, tribal nations or organizations work with IHS to plan, conduct, and administer one or more individual programs, functions, services or activities (PFSAs), or portions thereof, that IHS would otherwise provide; therefore, tribal nations or organizations may need IHS approval to make changes to PFSAs.[34]

When compacting, tribal nations assume full funding and control over PSFAs, or portions thereof, that IHS would otherwise provide; therefore, tribal nations or organizations do not need IHS approval to make changes.[35]

Are Urban Indian Health Centers Included in CHAP?

No, urban Indian organizations are not authorized to implement CHAP under the IHCIA.[36]

What Is Next?

The following list is not exhaustive; however, the IHCIA requires IHS to:

  1. Provide training for community health aides;
  2. Develop a training curriculum;
  3. Establish and maintain a certification board to certify community health aides;
  4. Develop and maintain a system that identifies continuing education needs of community health aides;
  5. Develop and maintain a system that supervises community health aides;
  6. Develop and maintain a system that reviews and evaluates community health aides; and
  7. Limit the scope of dental health work.[37]

Next Steps for Medicaid Expansion: Frequently Asked Questions About the 1115 Waiver

What is an 1115 Waiver, and what is the goal of the waiver?

An 1115 Waiver is an application to the federal Centers for Medicare and Medicaid Services (CMS), outlining a proposed experimental, pilot, or demonstration project that the state seeks to test and show that it will promote the objectives of Medicaid, namely, to keep families living on low-incomes healthy.

Did Montana submit a waiver previously for Medicaid expansion?

In 2015, Montana submitted an 1115 Waiver to CMS in its efforts to expand Medicaid coverage for adults with incomes at or below 138 percent of the federal poverty line (FPL). Montana’s 2015 waiver, approved by CMS, included new requirements that some Medicaid expansion enrollees pay premiums, up to 2 percent of the enrollee’s income and loss of coverage for some enrollees for failure to pay premiums.

How does this draft 1115 Waiver compare to the 2015 waiver?

The draft waiver amendment/extension largely reflects the language within HB 658, passed by the 2019 Legislature. The waiver does two main things:

  • Extends the current HELP provisions in the 2015 waiver, including the current exemptions from the demonstration. The waiver continues Medicaid coverage for adults with incomes at or below 138 percent FPL, as well as current requirements that some enrollees pay premiums. The waiver continues to exempt populations that were exempt from the first Medicaid expansion waiver. These exemptions include those who:
    • are medically frail;
    • have incomes below 50 percent FPL;
    • live in a region (including an Indian reservation) that would not be effectively or efficiently served through the waiver demonstration; or
    • require a continuity of coverage not available through the waiver demonstration.

The waiver will also extend the state’s 12-month continuous eligibility, providing enrollees continued benefits during a 12-month period.

  • Amends the current waiver to seek authority to implement new community engagement/work requirements and increased premiums reflected in HB 658. The waiver amendment largely mirrors the language within HB 658, as it relates to allowable activities, exemptions, and process for determining exemptions and compliance.

What is the timeline for the waiver process?

The state has opened the state comment period on the draft waiver, and the Department of Public Health and Human Services (DPHHS) will accept comments until midnight, August 15, 2019. DPHHS is required to submit the waiver to CMS by August 30. From there, CMS will also hold a federal comment period (likely 30 days). We do not know when CMS will approve the waiver, but it could take nine months to over a year before a waiver is approved.

What happens to Medicaid expansion coverage for current enrollees in the meantime?

Medicaid expansion coverage will stay in effect, in its current form, until CMS approves and the state implements the new requirements.

What does the new community engagement/work requirements mean?

After CMS approval and state implementation goes into effect, affected individuals will be required to work or perform some other approved activity (e.g., workforce training; secondary, postsecondary, or vocational education; substance abuse education or treatment; community service or volunteering) for a total of 80 hours per month.

Who will be subject to the work requirements?

Non-exempt enrollees between age 19 and 55 will be required to meet the requirements. Those who are already working and receive income that exceeds an amount equal to the average of 80 hours per month multiplied by the minimum wage will be exempt from the reporting requirements. HB 658 and the draft waiver also set out exemptions from these requirements, including those who are:

  • medically frail;
  • blind or disabled;
  • pregnant;
  • experiencing an acute medical condition requiring immediate medical treatment;
  • mentally or physically unable to work;
  • a primary caregiver for a person unable to provide self-care;
  • a foster parent;
  • a full-time student in secondary school or enrolled in at least six credits of postsecondary or vocational education;
  • participating in or exempt from work requirements of TANF or SNAP;
  • under the supervision of the Department of Corrections;
  • experiencing chronic homelessness;
  • a victim of domestic violence; or
  • living in an area with high-poverty designation.

Following approval from CMS, DPHHS will implement the new community engagement requirements, including reporting requirements and exemptions. DPHHS will notify an enrollee who is not in compliance that the enrollee has 180 days to come into compliance, and failure to comply within the 180-day period will result in suspension from the program. An enrollee who is suspended may be reinstated 180 days after the date of suspension or prior to that upon determination by DPHHS that the individual is back in compliance or meets an exemption.

Are there other new requirements in the waiver?

Some Medicaid expansion enrollees will be subject to increased premiums over time. Consistent with HB 658, the draft 1115 Wavier will require enrollees with income greater than 50 percent PL who are not otherwise exempt to pay monthly premiums. That premium level is set at 2 percent of the enrollee’s income for the first two years of participation. The premium level will increase 0.5 percent in each subsequent year that an enrollee receives coverage, up to a maximum of 4 percent of the enrollee’s income. DPHHS provided the below table on premium amounts for those subject to premiums.

Year of Participation in HELP Program Premium Amount

(percent of enrollee’s income)

Year 1 2 percent
Year 2 2 percent
Year 3 2.5 percent
Year 4 3 percent
Year 5 3.5 percent
Year 6 4 percent


How might these new requirements impact coverage in Montana?

The waiver includes information to CMS on how many people the state expects could lose coverage as a result of new community engagement/work requirements, consistent with the HB 658 fiscal note. The state estimates that 8,163 enrollees will be required to comply with the work requirements. Of those, half (4,081) are projected to lose coverage. The waiver amendment does not appear to provide projections for loss of coverage as a result of the new premium requirements.

How can someone make a comment on the proposed 1115 Waiver?

DPHHS will be accepting comments until midnight on August 15, 2019. Comments can be submitted by:

  • Mail: Medicaid Expansion Extension, Director’s Office, PO Box 4210, Helena, MT 59604;
  • Phone: (406) 444-2584; or
  • Email: dphhscomments@mt.gov.

DPHHS will also hold two public meetings, where individuals can provide public comment. The first meeting will be held in Billings on Wednesday, July 31, 2019, and the second will be in Helena on Thursday, August 1, 2019. More detail on the public meetings and comment period can be found at https://dphhs.mt.gov/medicaidexpext.

Individuals will also have the opportunity to provide comments on the federal level, once the state submits the waiver to CMS.

Timeline of the 1115 Waiver Process

June 14, 2019  DPHHS released the draft waiver, which can be found at https://dphhs.mt.gov/medicaidexpext
June 14 – August 15, 2019 State comment period for the draft waiver. Comments can be submitted by mail, phone, or email.
July 16, 2019 Tribal consultation to be held in Helena.
July 30, 2019 Children, Families, Health & Human Services Interim Committee will meet, where DPHHS will present the draft waiver.
July 31, 2019 Public meeting to be held in Billings.
August 1, 2019 Public meeting to be held in Helena.
August 15, 2019 Deadline for public comment to DPHHS.
August 30, 2019 DPHHS required to submit waiver to Centers for Medicare & Medicaid Services (CMS).
September 2019 (TBD) Federal comment period for comments to CMS (likely 30 days).
October 2019 through 2020 Negotiations between Montana and CMS on the waiver. It could take CMS somewhere between nine months to two years to approve the waiver.
Following CMS approval DPHHS will conduct rulemaking to implement the new requirements within HB658.



Access to Health Care Coverage for Nearly 100,000 Montanans Protected with Continuation of Medicaid Expansion

The Montana Legislature passed HB 658, a continuation of Montana’s Medicaid expansion program, providing health care coverage for over 96,000 Montanans. The Legislature enacted Medicaid expansion in 2015, but included a termination date on the law for June 30, 2019. Action in this legislative session ensures the continuation of Montana’s program, but includes some notable changes.

1. Current Exemptions from 2015 Waiver

HB 658 maintains the current exemptions for requirements set out in the 2015 waiver. These exemptions apply to premium requirements and the taxpayer integrity fee, and exempted those enrollees from the TPA plan (though this is no longer applicable due to actions taken during the 2017 Legislative Session). These exemptions include American Indians, medically frail, and those with incomes below 50% of the federal poverty line, and are maintained and moved to MCA 53-6-1304.

2. Community Engagement (Work) Requirements

The biggest change to the law is the “community engagement” (or work reporting) requirement for some enrollees. Those enrolled aged 19 to 54 and who do not meet one of the below exemptions specific to the work requirements will need to show they are working 80 hours per month. The law leaves it to DPHHS to put in place reporting requirements (i.e., how frequently, in what form) and the process DPHHS will undergo for verifying reporting.

a) Allowable Activities

The law lists several categories of allowable activities that will count toward 80 hours a month. DPHHS will likely further define these activities by rule:

    1. employment;
    2. volunteering;
    3. workforce training;
    4. secondary, postsecondary, or vocational education;
    5. substance abuse education or treatment; and
    6. other activities as defined by DPHHS that further the health purposes of Medicaid.

b) Exemptions

The law exempts a significant portion of enrollees from these new community engagement (work) reporting requirements. The law allows (and encourages) DPHHS to use existing data sources to verify exemptions, alleviating (in many, but probably not all, cases) the need for enrollees to self-attest to an exemption. Data used should include wage/income data, enrollment data, insurance claims data, and data from other safety net programs. The community engagement exemptions include:

    1. those with incomes that exceed an amount equal to the average of 80 hours per month multiplied by minimum wage (of annual wages of $8,160);
    2. medically frail;
    3. disabled, blind, or pregnant;
    4. experiencing an acute medical condition requiring immediate medical treatment;
    5. mentally or physically unable to work;
    6. a parent or other caregiver of someone unable to provide self-care;
    7. foster parent;
    8. full-time or part-time student enrolled in postsecondary education;
    9. meeting or exempt from TANF or SNAP work requirements;
    10. under supervision of corrections or county jail, including those on probation or parole;
    11. experiencing chronic homelessness;
    12. victim of domestic violence; or
    13. living in a high-poverty area.

An enrollee is temporarily exempt from the requirements if facing hospitalization or serious illness, caring for someone who is hospitalized or facing a serious illness, or impacted by a catastrophic event that prevents compliance. The exemption would apply during the reporting period(s) while facing such hardship.

c) Failure to Meet Community Engagement – Suspension – Reinstatement of Coverage

If a participant subject to the new community engagement requirements fails to meet or report activities or an exemption, DPHHS shall notify the participant of the requirements. At that point, the participant then has 180 days to come into compliance. If a participant fails to comply within the 180 days, DPHHS will suspend coverage for up to 180 days. However, DPHHS can reinstate coverage prior to the 180 days if: (i) the enrollee meets an exemption; or (ii) the enrollee meets the community engagement requirements for 30 days.

3. New Premium Requirements

For the narrow population of enrollees that are subject to premiums, HB 658 maintains the current requirement to pay premiums equal to two percent of enrollee’s modified adjusted gross income. However, the law then requires those individuals: (i) subject to premiums; (ii) who are enrolled for more than two years; and (iii) subject to the community engagement requirements, to pay higher premiums (increased by 0.5 percent each year after the second year). Those exempt from the “community engagement” requirements would be exempt from increased premiums. The 2019 law eliminates copays.

4. Taxpayer Integrity Fee (TIF)

The 2019 law maintains the fee imposed by Department of Revenue (DOR) for enrollees owning a certain amount of assets but makes significant changes to how it is calculated. First, the fee is now calculated using equity in particular assets. (Previously, the threshold values were calculated using the value of the asset, rather than equity in the asset.) Second, the fee will now apply if an enrollee meets any of the three asset calculations. (Previously, an enrollee had to have assets that exceeded all three prongs.)

The fee will apply if an enrollee owns:

    1. Equity in real property or improvements in real property that exceed $255,000; or
    2. Equity in more than one vehicle with total appreciable value that exceeds $25,000; or
    3. Ownership in agricultural land with taxable value that exceeds $1,500.

If a participant owns the above type of assets that exceed that asset limit, the enrollee is assessed a fee (by DOR) equal to $100 a month, plus $4 a month for each of the following:

    1. Each $1,000 in equity value in land above the $255,000 limit;
    2. Each $1,000 in equity value in vehicles above the $25,000 limit; and
    3. Each $100 of taxable value in ag land above the $1,500 limit.

5. Timeline

The current HELP Act (as passed in 2015) will stay in effect until December 31, 2019.

The law requires DPHHS to submit a new waiver to CMS by August 30, 2019. DPHHS will solicit public comment (law requires 60-day period) and submit the draft waiver to the Medicaid advisory council and the Children, Families, Health, and Human Services legislative interim committee.

CMS will then consider the waiver submitted and must provide a 30-day public comment period. Exactly how long CMS will take to approve the waiver is unclear (it will take at least 45 days from submission, but likely to take longer). As a reminder, CMS (under a different administration) approved Montana’s original waiver on November 2, 2015.

The new provisions within HB 658 (including community engagement requirement and increased premiums) go into effect on January 1, 2020. Many of these provisions will likely require DPHHS rulemaking. Enrollees subject to the community engagement requirements must come into compliance within 180 days of implementation.

Medicaid Expansion Works for Every County in Montana

Since Montana passed the bi-partisan Health and Economic Livelihood Partnership (HELP) Act in 2015, Medicaid expansion has been a vital source of health care coverage for nearly 100,000 Montanans. Each of Montana’s 56 counties is home to individuals, families, and workers who have benefitted from both preventive health services that detect treatable health concerns early and access to behavioral health services, such as counseling, addiction treatment services, and medications for mental illness.

All corners of our state benefit from Medicaid expansion. The program has been critical for the 18,000 businesses – large and small – across the state that have at least one employee enrolled. It has also helped thousands of Montanans find new and better employment opportunities and brought in millions of federal dollars now flowing through local economies.

Highlights of the data include:

  • County enrollment in Medicaid expansion ranges from 27 enrollees in Petroleum County (Winnet county seat with total county population of 523) to 14,118 enrollees in Yellowstone County;
  • In Ravalli County alone, 1,440 Montanans have accessed inpatient and outpatient treatment services for mental health needs;
  • Over 44,000 Montanans accessed counselors, doctors, support groups, or medication to treat and manage mental health issues or addiction;
  • 7,034 have received colon cancer screening, averting 2,554 possible cases of colon cancer;
  • More than 92,380 Montanans have accessed 300,000 preventive care services;[1]
  • Every county had at least 30 percent of their businesses employing at least one Medicaid-covered worker;[2] and
  • The Department of Labor and Industry provided approximately 29,000 Montana Medicaid clients with a variety of workforce services.[3]

Montana Medicaid expansion has proven to be a successful program, one that helps working families, employers, and the broader economy. From Carter County to Lincoln County, Medicaid expansion is working for Montana. The 2019 Legislature has all the facts it needs to reauthorize this bi-partisan, Montana-made health insurance program in its current form.

Appendix A provides county-specific data for Medicaid expansion total enrollment and percent of county population.[4]

Appendix B provides county-specific data for the number of Medicaid enrollees who have received preventive screenings, and the total number of total preventive health care services for Medicaid enrollees.[5]

Appendix C provides county-specific data for the number of Medicaid enrollees who have accessed inpatient and outpatient mental health services and substance use disorder treatment services.[6]  

Appendix D provides county-specific data for the number of Medicaid enrollees in Montana who use HELP-Link.[7],[8],[9]


Appendix A: Medicaid Expansion Total Enrollment and as Percent of County Population, January 2019

  Total Enrollment As Percent of Population   Total Enrollment As Percent of Population
Beaverhead 771 8.3% Madison 394 5.0%
Big Horn 2229 16.8% Meagher 243 13.1%
Blaine 780 11.8% Mineral 507 11.9%
Broadwater 349 6.2% Missoula 11,314 10.0%
Carbon 762 7.3% Musselshell 499 10.9%
Carter 48 4.1% Park 1,507 9.5%
Cascade 7322 8.9% Petroleum 27 5.6%
Chouteau 332 5.6% Phillips 353 8.4%
Custer 896 7.4% Pondera 823 13.2%
Daniels 60 3.4% Powder River 74 4.2%
Dawson 493 5.2% Powell 631 9.1%
Deer Lodge 961 10.5% Prairie 62 5.4%
Fallon 160 5.2% Ravalli 4,024 9.8%
Fergus 821 7.2% Richland 648 5.6%
Flathead 8,905 9.4% Roosevelt 1,837 16.2%
Gallatin 6,501 6.7% Rosebud 1,086 11.6%
Garfield 72 5.5% Sanders 1,322 11.6%
Glacier 2,690 19.6% Sheridan 180 4.9%
Golden Valley 120 14.1% Silver Bow 4,192 12.1%
Granite 194 6.1% Stillwater 520 5.6%
Hill 2,085 12.6% Sweet Grass 196 5.4%
Jefferson 619 5.4% Teton 570 9.4%
Judith Basin 149 7.5% Toole 499 9.7%
Lake 3,784 13.0% Treasure 60 8.7%
Lewis and Clark 5,639 8.6% Valley 527 6.9%
Liberty 218 9.2% Wheatland 279 13.3%
Lincoln 2,317 12.1% Wibaux 39 3.5%
McCone 165 9.7% Yellowstone 14,118 9.1%

Total Statewide Medicaid Expansion Enrollment 95,973 adults; 9.4% of the state population.


Appendix B: Medicaid Expansion Enrollees Who Have Accessed Preventive Screenings and Total Preventive Health Care Services, January 2019

Breast Cancer Screening Colon Cancer Screening Preventive Services Breast Cancer Screening Colon Cancer Screening Preventive Services
Beaverhead 86 71 836 Madison 45 37 405
Big Horn 73 142 2,012 Meagher 27 25 257
Blaine 61 54 780 Mineral 42 37 499
Broadwater 38 27 386 Missoula 870 666 11,689
Carbon 88 71 806 Musselshell 44 44 559
Carter 5 5 44 Park 100 114 1,520
Cascade 931 678 8,069 Petroleum 5 < 5 25
Chouteau 42 32 348 Phillips 31 25 390
Custer 86 65 922 Pondera 67 53 776
Daniels < 5 < 5 66 Powder River < 5 < 5 73
Dawson 33 31 530 Powell 60 54 662
Deer Lodge 62 93 1,027 Prairie 7 < 5 51
Fallon 11 9 153 Ravalli 323 352 4,123
Fergus 75 98 910 Richland 76 45 660
Flathead 1,024 813 9,547 Roosevelt 69 92 1,590
Gallatin 424 407 6,249 Rosebud 37 43 848
Garfield 7 5 71 Sanders 153 135 1,316
Glacier 103 102 2,021 Sheridan 19 10 185
Golden Valley 22 13 127 Silver Bow 336 280 4,399
Granite 20 16 211 Stillwater 53 40 512
Hill 169 113 2,156 Sweet Grass 13 16 174
Jefferson 64 60 760 Teton 62 36 576
Judith Basin 22 16 137 Toole 38 25 429
Lake 356 293 3,904 Treasure < 5 < 5 46
Lewis and Clark 434 514 5,989 Valley 45 49 595
Liberty 56 38 241 Wheatland 31 24 284
Lincoln 257 197 2,428 Wibaux < 5 < 5 38
McCone 15 11 144 Yellowstone 1,022 1,004 14,748

Total Preventive Screenings and Total Preventive Health Care Services for Medicaid Enrollees

7,901 have received breast cancer screenings and 7,034 adults have received colon cancer screenings


Appendix C: Medicaid Expansion Enrollees Who Have Accessed Inpatient and Outpatient Services for Mental Health and Substance Use Disorders, January 2019  

  Mental Health Outpatient Mental Health Inpatient SUD Outpatient SUD


Mental Health Outpatient Mental Health Inpatient SUD Outpatient SUD


Beaverhead 272 16 67 15 Madison 88 < 5 15 < 5
Big Horn 448 38 126 38 Meagher 28 9 5 < 5
Blaine 224 16 23 16 Mineral 176 16 56 < 5
Broadwater 107 6 18 < 5 Missoula 5,109 554 883 225
Carbon 226 40 37 10 Musselshell 123 10 49 6
Carter 8 < 5 < 5 < 5 Park 544 38 170 37
Cascade 2,716 315 752 204 Petroleum 0 < 5 < 5 < 5
Chouteau 49 11 8 < 5 Phillips 68 6 24 < 5
Custer 413 39 155 25 Pondera 141 15 13 9
Daniels 6 < 5 < 5 < 5 Powder River 10 < 5 7 < 5
Dawson 211 22 122 21 Powell 166 15 49 14
Deer Lodge 359 21 155 17 Prairie 14 < 5 < 5 < 5
Fallon 38 6 15 < 5 Ravalli 1,340 100 277 51
Fergus 240 32 66 20 Richland 186 22 113 36
Flathead 2,829 381 471 116 Roosevelt 446 21 61 34
Gallatin 2,147 89 443 98 Rosebud 254 48 62 38
Garfield 12 < 5 < 5 < 5 Sanders 326 36 71 19
Glacier 569 40 28 35 Sheridan 47 8 21 < 5
Golden Valley 15 6 6 < 5 Silver Bow 1,611 81 760 100
Granite 35 5 10 < 5 Stillwater 127 13 26 8
Hill 759 39 271 92 Sweet Grass 47 5 16 6
Jefferson 215 13 60 6 Teton 101 13 14 < 5
Judith Basin 19 < 5 < 5 < 5 Toole 122 12 16 7
Lake 1,211 83 361 106 Treasure 11 < 5 < 5 < 5
Lewis and Clark 2,239 200 606 125 Valley 176 23 71 < 5
Liberty 23 5 5 < 5 Wheatland 42 12 10 < 5
Lincoln 738 52 174 31 Wibaux 8 < 5 < 5 < 5
McCone 22 < 5 6 < 5 Yellowstone 5,836 878 1,708 560

Total Medicaid Enrollees Who Have Accessed Inpatient and Outpatient Services for Mental Health and Substance Use Disorders

30,980 adults have received outpatient mental health services

3,291 adults have received inpatient mental health services

7,837 adults have received substance use outpatient services

2,099 adults have received substance use residential services


Appendix D: Businesses Employing Medicaid Expansion Clients by Total Number and as Percentage of All Businesses, and Total Number of HELP-Link Clients, January 2019

  Businesses Employing Enrollees Percent of Businesses HELP-Link Clients Businesses Employing Enrollees Percent of Businesses HELP-Link Clients
Beaverhead 179 60.1% 203 Madison 156 56.5% 74
Big Horn 87 55.8% 560 Meagher 38 61.3% 22
Blaine 65 65.7% 162 Mineral 52 74.3% 88
Broadwater 60 52.2% 83 Missoula 1,836 61.8% 3,508
Carbon 151 57.9% 96 Musselshell 51 55.4% 87
Carter 9 37.5% 6 Park 316 57.6% 339
Cascade 998 60.8% 2,942 Petroleum 6 75.0% 3
Chouteau 57 55.9% 48 Phillips 57 55.9% 62
Custer 177 61.9% 448 Pondera 57 45.6% 129
Daniels 17 34.7% 4 Powder River 28 49.1% 7
Dawson 96 48.5% 288 Powell 63 56.8% 161
Deer Lodge 89 59.3% 317 Prairie 13 54.2% 18
Fallon 50 45.5% 25 Ravalli 555 58.7% 1,056
Fergus 164 56.9% 345 Richland 151 41.0% 358
Flathead 1,614 60.8% 2,401 Roosevelt 97 64.7% 613
Gallatin 1,873 51.5% 1,360 Rosebud 76 57.1% 175
Garfield 15 53.6% 7 Sanders 168 69.7% 391
Glacier 94 63.9% 705 Sheridan 52 46.0% 24
Golden Valley 11 91.7% 6 Silver Bow 457 64.0% 1,334
Granite 39 62.9% 28 Stillwater 70 43.5% 101
Hill 210 63.6% 850 Sweet Grass 55 47.0% 18
Jefferson 104 54.5% 151 Teton 88 56.4% 73
Judith Basin 22 44.0% 18 Toole 64 54.7% 102
Lake 360 67.3% 1,629 Treasure 5 31.3% 5
Lewis and Clark 845 54.7% 1,930 Valley 110 62.1% 200
Liberty 23 46.9% 17 Wheatland 35 57.4% 19
Lincoln 302 67.7% 924 Wibaux 6 30.0% 8
McCone 16 40.0% 10 Yellowstone 2,009 53.3% 4,207

Proposed Work and Reporting Rules Could Hurt Montana Veterans

Military veterans and their families are among the more than 95,000 Montanans who have benefited from the expansion of Medicaid. As many as 7,000 Montana veterans have gained access to quality, affordable health care through the Health and Economic Livelihood Partnership (HELP) Act.[1]

Proposals to impose strict work and reporting requirements and raise premiums for Montanans who receive health care through Medicaid will create unnecessary barriers for veterans to get the health care they need, and make it more difficult to maintain health, employment, and housing stability. Medicaid expansion has helped thousands of Montana’s veterans access health services. Efforts to kick people off their health care coverage dishonors those who have already served us.

Not All Veterans Qualify for VA Health Care

Contrary to what many assume, veterans often do not have automatic and easy access to health care provided by the Department of Veterans Affairs (VA), despite their service to our country. Not all veterans are eligible to receive health insurance through the VA and, for those who are, coverage can be limited. The VA considers several factors including length of service, service-related disabilities, income, and condition of discharge to determine eligibility and priority for covered health care services. For example, a veteran who drove a tank is classified as 10 percent disabled due to hearing loss from tank noise. The VA will provide care for hearing loss but will not cover the cost of a gall bladder surgery.[2] Reserve or National Guard soldiers may not qualify because they are called up only for training purposes but cannot earn enough active service time to be eligible.[3]

Access to the VA Medical Center Severely Limited in Montana

Veterans who qualify for VA health care face challenges getting the care they need because some services are not available at all VA community centers. In Montana, there is just one VA hospital, Fort Harrison Medical Center near Helena, and 17 community-based outpatient centers dispersed across the state.[4] In many cases, individuals may live too far from a VA center to be able to routinely get care. This is particularly true for those living in rural communities. For example, veterans typically seen at the Miles City clinic must travel six hours each way for VA services only available at the hospital at Fort Harrison.  Furthermore, long-identified staffing shortages at the Fort Harrison Medical Center and outpatient centers have led to long wait times and appointment backlogs, making it even more challenging for veterans to receive timely care.

Medicaid Expansion Improves Veterans’ Health Care

Nationally, among veterans covered by Medicaid in 2015, almost two in five have Medicaid as their only source of health coverage, while Medicaid supplements other coverage for the remaining three in five.[5] From 2013 to 2015, Medicaid coverage of non-elderly veterans increased by almost a third in states that expanded Medicaid.[6] Since health care reform was implemented, fewer veterans report having unmet health needs due to the cost of care and report having trouble paying medical bills.

Furthermore, Medicaid provides coverage for veteran’s family members who rarely qualify for veterans benefits. In 2015, more than 660,00 veterans’ spouses were enrolled in Medicaid nationally.[7] 

For approximately 7,000 veterans in Montana, Medicaid provides a critical source of affordable health coverage, covering many who might otherwise be uninsured and, for others, supplementing private or military health insurance. Roughly three-quarters of all Montana veterans are eligible for VA health care services but less than two-thirds are enrolled with the VA health care system in Montana, electing to access health services outside the VA system.[8]

Work Requirements Puts Veterans At Risk of Losing Coverage

Nationally, veterans with Medicaid coverage often have complex health needs: 42 percent have two or more chronic health conditions, 54 percent have a disability, 11 percent live with severe mental illness, and 12 percent have a substance use disorder.[9] Although veterans with complex health needs could be eligible for exemptions from work and reporting requirements, the added bureaucratic obstacles and complex reporting systems required to prove eligibility will make it harder to navigate the health care system due to the nature of these conditions. Veterans are also more likely to experience homelessness and, while some states include limited exemptions for people experiencing homelessness, additional reporting rules will create another barrier to stable housing and employment.[10]

Imposing strict work and reporting requirements and raising premiums will make it harder for veterans to access health care. For the many veterans already facing complex health needs and housing instability, these harsh requirements and additional bureaucratic hurdles will lead to more individuals becoming uninsured, going without needed health care, or facing higher medical bills, leading to greater instability in their lives. In addition, taking Medicaid coverage away from veterans shifts a greater burden to the VA when the system is already under-resourced and short-staffed and where veterans experience months-long wait times to see a doctor.[11]

Montana’s Medicaid Expansion Connects People with Health Care and Work

Montana’s expansion of Medicaid to adults with incomes less than 138% of the federal poverty level has provided health care coverage to 95,000 Montanans. Proposals to take health care coverage away from people who do not meet strict requirements to work a specific number of hours each month (and then report on that work) could hinder access to health care for thousands of these newly-covered individuals, many of whom are working or are unable to work. Arkansas is the first state to take coverage away from people who do not meet a work and reporting requirement, and it has already seen thousands of people lose their health care. While these burdensome requirements especially endanger coverage for those with significant barriers to work, they also can harm young children, rural Montanans, individuals with disabilities, many American Indians, and penalize people who are already working.

Instead of putting measures in place that take away health insurance at a time when someone most needs it, Montana has the opportunity to bolster its successful HELP-Link workforce training program, which has reached over 25,000 Montanans and helped to improve access to targeted workforce assistance.

The Success of Montana’s Health and Economic Livelihood Program

Montana’s expansion of Medicaid, the Health and Economic Livelihood Partnership (HELP) program, has had many economic, health, and employment benefits for the state and its participants. While expansion covers individuals with incomes under 138% of the federal poverty level (FPL), nine out of ten enrollees are living below poverty. As of December 2018, 95,000 adults were enrolled in the HELP program and, to date, 90,000 enrolled Montanans have accessed preventative health care services.[1]

In addition to improving access to health care for Montanans living with low-incomes, HELP has brought the state significant economic benefits, including $58 million in state budget savings and $47 million in new tax revenue.[2] Additionally, the program created 5,000 new jobs and generated $270 million in new personal income for Montanans across the state. The HELP-Link program has helped thousands of Montanans secure employment, and workforce participation has increased among Montanans living on low-incomes. HELP has also transformed access to health care for many American Indians. Medicaid supports Indian Health Service (IHS) and tribal facilities by paying 100 percent of the costs of care for American Indians who are enrolled in Medicaid and receive care at these facilities. That helps ensure that IHS and tribal facilities have the resources needed to maintain and increase their capacity to provide care.

HELP-Link Meets Workforce Needs Better Than Work Requirements

Montana already has an innovative solution to help people on Medicaid gain access to stable employment. The HELP-Link program has connected 25,244 people who are enrolled in Medicaid to Department of Labor and Industry (DLI) employment services.[3] HELP-Link provides intensive one-on-one support that has helped over 3,000 receive employment training services.[4]

Unlike work requirements, which mostly monitor the hours of people who are already working and take coverage away from those who do not, HELP-Link is a workforce promotion program focused on those that need training and assistance. These services include job seeker workshops, assistance for training in high-demand sectors, credit history counseling, and on-the-job-training programs. The program also connects people to other services such as home health aides, childcare, and housing. By addressing actual barriers to work, HELP-Link has been effective at raising employment as well as earnings.

The results for participants have been significant. Of the 3,150 Medicaid clients that completed the DLI workforce training programs in 2016, 70 percent were employed after finishing their training.

Over half of those employed had higher wages after completing the program, with an $8,057 wage gain over the previous year.[5]

Medicaid expansion and the HELP-Link program may have significantly raised employment rates among Montanans living on low-incomes, according to the Bureau of Business and Economic Research at the University of Montana.[6] For Montanans with disabilities living below poverty, there was a 6 percentage-point increase in labor force participation between 2015 and 2016. For Montanans without disabilities, there was a 9 percentage-point increase. Other states did not see similar employment gains during the same period, nor did Montana see similar employment gains among those with higher income levels.[7]

Because Montana has already been able to significantly increase labor force participation among Montanans living on low-incomes, enacting burdensome and expensive work requirements would only distract from Medicaid’s goal of providing health care coverage to individuals who need it. Work requirements ignore the reasons people are not in the labor force, whereas the HELP-Link program helps them overcome these barriers and is a national model for other states looking at ways to help Medicaid enrollees improve employment opportunities.

Harsh Requirements Result in Loss of Coverage for Thousands of Enrollees

Proposals to take health care coverage away from people who do not meet stringent work and reporting requirements jeopardize the successes of Medicaid expansion. This could be especially true in rural Montana and Indian Country, where Medicaid has been an important source of health care coverage to communities facing high barriers to care and unemployment rates. As of 2017, almost half (48 percent) of Medicaid expansion enrollees resided outside of Montana’s seven largest urban areas.[8]

Arkansas was the first state to implement a federal Medicaid waiver requiring enrollees meet monthly work and reporting requirements. To date, nearly 17,000 Arkansans have lost health insurance, and the state continues to face serious difficulties administering the burdensome requirements (see case study).[9]

Acknowledging the detrimental impacts these harsh requirements have on access to health care coverage, courts have stepped in to block some states from implementing work requirements. In June, a federal judge stopped a Kentucky plan to introduce requirements that would have caused 95,000 individuals to lose Medicaid coverage.[10] Further, in recognition of the significant loss of coverage in Arkansas, the Medicaid and CHIP Payment Access Commission (MACPAC) sent an unprecedented letter to the Trump administration to reconsider approving any other states’ requirements until the federal Department of Health and Human Services can adequately evaluate and monitor the effects.[11]

Work Requirements Jeopardize Access to Health Care and Increases Costs for Rural Hospitals

Withholding health care from people with significant barriers to work exacerbates the issues that Medicaid expansion has been successful in addressing. As has been the case in Arkansas, many individuals who are trying to work are often kicked off health insurance at a time when they most need it. In many instances, individuals are unaware of the requirements, whether an exemption applies, or how to maneuver the complex filing requirements to verify work or an exemption.[12] Losing Medicaid coverage could lead to gaps in health care for individuals, then making it increasingly difficult to gain or maintain steady employment for those with chronic health conditions. With the gains that Montana has made in expanding coverage to more residents, harmful penalties would move us in the wrong direction.

As work requirements push people off of Medicaid coverage, health care providers – especially rural hospitals and IHS and tribal facilities – likewise suffer. Medicaid expansion has brought $11.7 million in Medicaid revenue for community health centers, and providers have seen a 49% decrease in uncompensated care.[13] With fewer Montanans enrolled in Medicaid, providers would once again be forced to pick up the tab for uncompensated care. This shift would endanger rural hospitals already facing declining populations, high poverty rates, and low levels of private insurance.[14] The same is true for IHS and tribal facilities. Making it harder for American Indians to enroll in and maintain Medicaid coverage would reduce federal funds for the IHS and tribal facilities that provide care to American Indians. That could force them to cut their capacity to treat patients, even as the share of American Indians lacking health insurance and other options for care remains high. The head of the Centers for Medicare and Medicaid Services Tribal Technical Advisory committee has warned that “without supplemental Medicaid resources, the Indian health system will not survive.”[15]

Case Study: Arkansas Sees Unprecedented Loss of Coverage as a Result of Harsh Work Requirements

Arkansas became the first state in the nation to impose work requirements on Medicaid beneficiaries. While Arkansas’s work requirements have not yet been fully implemented, nearly 17,000 people have already lost their health insurance since the state began applying the policy to adults aged 30-49 in June 2018. Even more beneficiaries are likely to lose coverage when the policy is extended to those aged 19 to 29 in January 2019. Arkansas requires individuals subject to the requirements to report on their work activities monthly through a complex online portal. While the state put in place a series of exemptions, many enrollees struggle to understand how to apply for an exemption or how often to report their exemption (each exemption varies). Nearly 22 percent of all beneficiaries subject to the new policy have lost coverage so far – significantly higher than the 6 to 17 percent coverage loss that Kaiser Family Foundation researchers forecasted could result from implementing work requirements nationwide. Confusion over the new system, a lack of awareness, or difficulty accessing internet caused difficulty in complying with the reporting requirements. Without health insurance, many Arkansans face unmet physical and mental health care needs, and providers are again left with uncompensated care costs.

In October, 10,768 Arkansas Works beneficiaries were required to report that they work, engage in job training or volunteer for at least 80 hours a month to comply with the new work requirement policy. Among those who needed to document their work activities in October, only 1,428 people were able to report satisfying this requirement. An additional 914 enrollees newly filed for exemptions.

Out of the remaining 8,426 beneficiaries, only 118 people reported some activities but not enough to satisfy the 80 hours per month requirement. This could mean that many people who did not report and satisfy the requirement did not know about the new regulations or were unable to create accounts and navigate the online portal.

For people who are looking for work but unable to find any, the new requirement is especially difficult. Beneficiaries can only count 39 hours of combined job search and job search training towards their 80-hour requirement. The exemption for attending school is also limited, putting many people striving to improve their workforce readiness at risk of losing health care coverage.

Even if work requirements could somehow avoid unintended consequences, they would still do harm. Specifically among those who are not working and do not qualify for exemptions, as many face major barriers to work and have serious health needs.

Source: Arkansas Department of Human Services

Work Requirements Do Not Increase Workforce Participation

Not only do work requirements hinder Medicaid’s goal of expanding health care access, they are also unsuccessful at achieving the stated goals of increasing work or decreasing poverty. When work requirements have been imposed, research shows that employment increases were modest and faded over time. Stable employment among beneficiaries subject to requirements was the exception, not the norm, and most enrollees with significant barriers to employment never found work.[16]

The vast majority of Medicaid beneficiaries who can work, do work. Out of those who are not employed, virtually all are facing either health-related barriers to employment or labor-force barriers.[17] In fact, in recognition of insufficient employment opportunities, the Department of Public Health and Human Services waived certain work requirements for the Supplemental Nutrition Assistance Program for 33 counties and six of the seven reservations in Montana.[18]

A Brookings Institute analysis of 2013-2014 Census Bureau survey data found that for Medicaid enrollees aged 18-49 with no dependents under age six, only 1.1 percent do not work because they are not interested in working. For those aged 50-64, only 1.4 percent are not interested in working for pay. For those who are actively participating in the labor force yet not working for pay, the most common reasons cited are work-related (e.g. cannot find a job, recently laid off). For those who are not actively participating in the labor force, the most common reasons cited are health or disability related. Health or disability reasons are cited significantly more among Americans aged 50-64.[19]

In Montana, the vast majority of Medicaid enrollees already work. Two-thirds of all non-elderly adult Medicaid enrollees work.[20] Only one in five live in a household with no worker present. Of those not working in Montana, 37 percent are ill or disabled, 33 percent are caretaking, and 18 percent are attending school.[21]

Montana HELP Plan participants fill out a survey upon enrollment about their employment situation and barriers to employment. The most common reasons for not working cited were personal finances/credit history and felony/misdemeanor convictions (see Table 1). Proposals to push people off of health care who are unable to meet monthly requirements do nothing to address these barriers to work.

Rather than using state resources to help people access work, these requirements waste taxpayer money tracking hours people are already working. Montana allocated just $885,500 for HELP-Link’s outreach, trainings, and linkages to other services in FY19. In contrast, Kentucky planned to spend $187 million in FY19 to implement its reporting program.[22]

Frequent reporting is also more difficult for rural program beneficiaries. Montana ranks 50th in the nation for access to broadband internet.[23] A lack of internet connection could mean working individuals lose their health care coverage if they are unable to report their hours worked on time even if they have worked enough to qualify for coverage. With two-thirds of non-elderly adult Medicaid enrollees in Montana already working, for the majority of enrollees, work requirements would only create additional demands without increasing their employment.


Barriers to Employment
Help-Link Participants Help-Link Survey Completers
Total % of Total Identifying Barriers Total % of Total Identifying Barriers
Personal finances/credit history 226 16.9 1471 26.3
Felony/misdemeanor conviction 168 12.6 1265 22.6
Lack of transportation 130 9.7 1139 20.4
Poor physical health 113 8.4 778 13.9
mental illness 88 6.6 655 11.7
physical disability 85 6.4 532 9.5
lack of childcare 75 5.6 810 14.5
lack of housing 69 5.2 585 10.5
lack of telephone 57 4.3 554 9.9
caring for a family member with health issues 51 3.8 483 8.6
learning disability 47 3.5 320 5.7
probation 37 2.8 346 6.2
drug or alcohol addiction 35 2.6 264 4.7
domestic violence 26 1.9 193 3.5
court mandated programs or classes 16 1.2 150 2.7
pending felony/misdemeanor 8 0.6 139 2.5
Number Identifying at Least One Barrier 1,338 45.1 5,593 45.6
Total 2,968 12,270

Source: Montana Department of Labor and Industry


Work Requirements Harm Workers and Those Who Cannot Work

Not only do monthly reporting requirements fail to increase workforce participation, they also create additional challenges for those who cannot work and those who are already working but in part-time jobs with volatile work schedules.

Monthly reporting requirements fail to accurately reflect workforce participation. In a one-month snapshot of the general population, 20 percent of the population is either out of the labor force or unemployed, according to research by the Hamilton Project. But over a two-year period, 90 percent of the population has been employed at some point. Many workers regularly cycle in and out of employment, and this is especially true for people who are working in low-income jobs. In a given month, 39 percent of Medicaid enrollees are not working. Over two years, however, that number drops by ten percentage points, to 29 percent of Medicaid beneficiaries who are not working.[24] A single month with an unexpected illness, reduced hours, or loss of a job could mean a worker in a low-wage job loses their health care coverage as well.

Workers with low-incomes are especially subject to the volatility of the labor market.[25] Out of those employed, 22 percent of Medicaid participants worked over 20 hours in at least one month within a two-year time span but did not do so in other months, the research showed. This volatility is especially common in rural areas where jobs like farming, manufacturing, and retail commonly feature variable hours, involuntary part-time work, and irregular scheduling.[26] Nearly half (48 percent) of Medicaid expansion enrollees reside outside of Montana’s seven largest urban areas, making it more difficult for them to find work.[27]

Many hardworking Montanans who work in vital Montana industries like agriculture, construction, and health care could lose their health care coverage if they fail to meet the set hourly requirements one month. One in five Montana Medicaid enrollees work part-time and could be subject to losing coverage.[28] Nearly half (48 percent) of Medicaid enrollees in Montana work in the agriculture or service industry, namely construction. Twenty percent work in education or health, fields with many part-time and variable hours.[29]

Older Montanans will encounter additional obstacles. Older workers often face barriers maintaining steady employment due to health conditions that make it difficult to consistently meet hourly work requirements. Age discrimination also makes it more difficult for older people to find new employment or maintain their current position.

Taking away health care would only make it more difficult for people who want to increase the number of hours they work. A survey of Medicaid beneficiaries in Ohio and Michigan found that one-half to two-thirds of respondents said that having health care coverage made it easier for them to look for work, made it easier to work, or made them better at their jobs.[30] Rural Montanans who are often facing greater physical and mental health challenges would be especially hard hit.[31]


Montana’s HELP-Link is already successful at connecting people with health care and jobs. Instituting new, harsh requirements would only serve to jeopardize this success.

Because most people on Medicaid who can work do work, proposals to take health care away from people not working a set number of hours each month do not encourage workforce participation. Instead, they only serve to increase barriers to health care, and in turn, make it more difficult for program participants to maintain steady employment.