Montana began enforcing Medicaid work requirements on Oct. 1, and patients across the state say they still do not understand who qualifies or how to prove it. The rules apply to able-bodied adults enrolled in the state's Medicaid expansion program.
Under the policy, most enrollees ages 19 to 64 must document at least 80 hours per month of work, job training, school or volunteer service. People who fail to report that activity risk losing their health coverage.
The confusion is widespread. Enrollees told NPR they received conflicting information from state notices, help lines and local clinics. Some said they did not know the reporting deadline had arrived until days before it hit.
"I kept calling and getting different answers," one enrollee told NPR. "Nobody could tell me for sure if my hours counted."
Montana is one of a handful of states moving forward with work requirements after federal courts blocked similar rules in other states in recent years. The Trump administration has encouraged such policies, and Arkansas became the first state to implement them in 2018. Roughly 18,000 people lost coverage there before a federal judge halted the program.
State health officials say they have mailed notices and set up online portals for enrollees to report their hours. Advocates say the outreach has not been enough, especially in rural counties with limited internet access.
Health clinics and hospitals warn the fallout could stretch beyond patients. Uninsured residents often delay care and end up in emergency rooms, shifting costs to providers and taxpayers.
Coverage losses will not happen immediately. Montana has built in a grace period, and enrollees who fall short will get warnings before their benefits are cut. But advocates say even a temporary gap in coverage can disrupt prescriptions and ongoing treatment.
Enrollment numbers will be the clearest measure of the policy's impact. State data on how many people lose coverage is expected in the coming months, and both supporters and critics say they will watch those figures closely.
For now, patients say the biggest problem is simple: they cannot get a straight answer about what the law requires of them.
