In Montana, Navigating Medicaid Changes Forces Patients to ‘Jump Through Hoops’

Filling out paperwork for those in need of Medicaid is already a complex process, one where people can fall in between the cracks due to procedural reasons, not because they’re ineligible. 

During the redetermination process in 2023 after the public health emergency policies around COVID-19 ended, nearly two-thirds of Montana Medicaid enrollees lost coverage despite being eligible, according to the Montana Healthcare Foundation. That was due to technical issues, such as incomplete paperwork. 

This issue is exacerbated for those trying to access behavioral health services at places like Western Montana Mental Health Center, CEO Bob Lopp said. With 21 clinics across the region, the center provides a comprehensive suite of mental health resources and substance use assistance, including group homes, prevention services, treatment programs, and veteran services.  

For Lopp’s center, along with hospitals and health care organizations across the state, more enrollees could lose Medicaid coverage with the passage of H.R. 1, the One Big Beautiful Bill Act. The Medicaid landscape is set to shift in several ways under the new law, including changes to funding, work requirements and eligibility checks.  

“It’s going to mean that it’s harder for people that are in need to be able to use the services that we have that we provide in the mental [and] behavioral health world,” said Lopp. 

The federal shifts to Medicaid arrive against the backdrop of a state legislature that extended Medicaid expansion this spring. Medicaid expansion covers health care costs for 76,255 people in the state, according to April figures from the state health department. That includes more than 7,000 adults in Flathead County, which has the third highest number of Medicaid expansion enrollees in Montana.  

The efforts to extend Medicaid expansion were an area of bipartisan consensus at the legislature, as a coalition of Democratic legislators and some Republicans passed House Bill 245, the bill that extended the program.  

Medicaid expansion also proved popular among Montana voters. The Montana Free Press-Eagleton poll, which was released in May and included responses from more than 900 Montanans, found 59% of respondents strongly supported Medicaid expansion. Another 18% somewhat supported Medicaid expansion. Those figures included Democrats, Republicans and independents. 

State Rep. Ed Buttrey, R-Great Falls, carried the legislation to extend Medicaid in Montana. Buttrey has carried legislation to create and renew Medicaid expansion in the state for years. At the beginning of the month, he also transitioned into a new role as president of the Montana Hospital Association. Over the years, Buttrey has developed a “love” for healthcare policy. He’s proud of the state’s work on Medicaid.   

Buttrey sees positive aspects in the shifts to Medicaid from H.R. 1, the One Big Beautiful Bill Act, among them a $50 billion Rural Health Transformation Fund that will be split over the next five years between all states that submit applications. He anticipates it will funnel millions of dollars to help Montana’s rural health systems recruit physicians, create partnerships and fill gaps in preventive and other types of care. 

“The downside of it is it’s a five-year program, so you can kind of get used to all this funding, and then in 2030 it goes away,” Buttrey said. “What do you do? We have to plan for that.” 

Rural clinics, for their part, have concerns about how that support will manifest. The Montana Healthcare Foundation estimates that two-thirds of Montana Medicaid enrollees live in rural regions, and that more than 60% of enrollment losses from H.R.1 would be from those in rural areas. 

There are still some ambiguities regarding the rural health fund that makes exactly how it will help rural hospitals in Montana unclear. For one, the rural health fund is temporary, something Buttrey acknowledged. Meanwhile, many of the impacts to Medicaid in the law do not have a proposed sunset.  

The rural health fund is also planned to be split, with $25 billion distributed equally among states with approved applications, and the other $25 billion to be handed out based on an approach yet to be determined by the Centers for Medicare and Medicaid Services (CMS).  

Rural hospitals are already planning ways to creatively fill in funding gaps. Providence St. Joseph Medical Center recently broke ground on a rural health clinic, for which staff had raised $14 million in the past year through donors, said Chief Administrative Officer Caryl Perdaems. 

“I think when you’re looking at a trillion dollars in Medicaid cuts, that’s going to affect everybody,” Perdaems said. “We’re planning strategies to look at how we are lifting up our programs, but we’re also leaning into our donor support.”  

Buttrey identified other challenges with H.R. 1 and its implementation. One area Buttrey raised issues about was the speed with which the state is pressing forward when it comes to enacting work requirements.  

States will have to enact federally mandated work and community engagement requirements for Medicaid eligibility by 2027. Medicaid enrollees will be required to work, complete community service, participate in a work program or enroll in an educational program part-time, for a total of at least 80 hours per month. There are some exceptions. The bill also requires compliance verifications every six months.  

Montana is pursuing an earlier implementation date for work requirements by seeking a Section 1115 Waiver. The state is holding a virtual public meeting Aug. 1 from 3 p.m. to 5 p.m. to present information about the plan. It also held two other hybrid meetings about the proposal earlier this week — one for tribal consultation, and the other for the public. For more information, visit the DPHHS website. 

Community engagement requirements have been baked into the state’s Medicaid expansion since 2019 but have never been implemented. That’s thanks, in part, to delays from the COVID-19 pandemic.  

But should the Section 1115 Waiver be approved by the CMS, work requirements could come to the state as soon as 2026, putting Montana ahead of the federal deadline.  

But can the state of Montana handle doubling the workload of verifying income and other things for eligibility?

State Rep. Ed Buttrey, R-Great Falls

A draft proposal estimates about 17.5% of Medicaid expansion enrollees will lose coverage thanks to the community engagement requirements. An additional 1.5% to 2.5% of enrollees will also be disenrolled because of premiums.  

In Buttrey’s view, the early implementation could pose problems for the state.  

“It’s a little bit concerning,” he said, “because part of ensuring that you have a successful work requirement in a program like this is that if you’re going to verify work hours and work wages, you need to have a system to do that, and you don’t want to be backlogged.”  

He worries the state doesn’t have enough full-time employees or a computer system to verify employment. In turn, by implementing that requirement too early, Buttrey worries people who qualify for coverage could be thrown off the plan. 

The work requirement is coupled with federal rules that states must go through redetermination for the Medicaid expansion population twice a year, instead of on an annual basis.  

“Again, you know, we want to make sure the right people that really need the program and the benefits are getting them,” Buttrey said. “But can the state of Montana handle doubling the workload of verifying income and other things for eligibility?” 

Montana’s legislative Democrats wrote a letter earlier this month to Charlie Brereton, the director of the state’s Department of Public Health and Human Services, opposing the submission of the 1115 Medicaid demonstration waiver. It argued the submission of the waiver is “premature,” and railed against work requirements for Medicaid.  

“Instead of increasing labor participation, all that work requirements do is force people to jump through hoops to prove to bureaucrats what they’re already doing,” the letter stated. “People working multiple jobs or providing care for a loved one don’t have the time or capacity to fill out piles of paperwork, so they will lose their coverage for administrative reasons — not because they don’t qualify for coverage.” 

Lopp, at Western Montana Mental Health Center, knows a woman who is currently serving as the primary caregiver for her younger brother, who is autistic. The two qualify for Medicaid. But with the new changes, Lopp said she’ll have to “go through all the hoops” to prove that she’s caring for a disabled person before receiving the support that she needs. Applying for an exception will likely be a burdensome process with the new eligibility requirements. 

Lopp said with her options, she might consider going back to work and pay to have her brother live at one of Western Montana Mental Health Center’s group homes, where the care is “way more expensive than it would have been to have them supported at home.” 

“We’re always trying to get people down to a lower level of care, as appropriate,” Lopp said. “So now you’re moving somebody from a lower level where it costs less to a higher level where it’s going to end up costing us more.”  

To meet the community engagement requirements, Lopp said the center is planning to redirect some employees and shunt resources toward care navigation to help people through the “Byzantine rules of the system.”  

The center has limited resources and staff, however, which means that redirecting staff and resources will require taking “resources away from actual care delivery to help make sure people properly get through the front end of the system,” Lopp said.  

Lopp warns of the downstream results of less people having access to critical behavioral health care. He said it could put more pressure on local safety resources like the first responders, the sheriff’s office, police departments, and local jails.   

“You’re going to see in a couple of years that this will have to turn back the other way, because everybody’s going to say, ‘well, wait a second, how come I have twice as many homeless people down in Depot Park?’” Lopp said. “Because we’re spending more time on the street, working with people that could’ve been helped if we were doing good mental health services and making it easier for people to get there, not harder.”  

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