Frequently Asked Questions
Starting on July 1, 2026, under the House Reconciliation bill (H.R. 1), also known as “H.R. 1” or the “One Big Beautiful Bill Act,” Montana will introduce community engagement requirements for certain Montana Medicaid members.
This FAQ reflects information known as of the publish date and can change as updates from CMS become available.
The FAQ below covers the following topics:
- Implementation timeline and key dates
- Overview of community engagement requirements
- Who is affected by the community engagement requirements
- Who is excluded
- Compliance and verification
- Interaction with other programs
- Six-month redetermination
- Appeals and coverage protections
- Eligibility worker operations and state systems
- Stakeholder engagement and updates
- Broader policy and impact
What are the new community engagement requirements?
The community engagement requirements require non-excluded adults on Medicaid Expansion, ages 19-64, to participate in community engagement activities to keep their health coverage.
The main community engagement requirements are:
- 80 hours a month: You must spend at least 80 hours each month doing certain activities.
- You can meet these hours through:
- Working at a job
- Community service or volunteering
- Workforce training or job readiness programs through the State of Montana
- Going to school
- Mixing activities: You can mix these together. For example, you could work 60 hours and do community service for 20 hours.
These community engagement requirements apply to you if:
- You are between the ages of 19-64.
- You are covered under the Medicaid Expansion (low-income adults).
- You do not have an exclusion.
What will happen on July 1?
Montana will go-live with implementation of community engagement requirements for the Medicaid Expansion population on July 1, 2026.
- For new applicants: All new applications for Medicaid Expansion on and after July 1, 2026 will be required to meet community engagement requirements through qualified activities, unless they have a verified exclusion.
- For existing clients: All clients will not immediately need to demonstrate compliance on July 1; rather, compliance will be required at your next scheduled redetermination. Cases with a redetermination date of August 31, 2026 will be the first to be required to meet community engagement requirements.
What is the “hold harmless” period?
From July through September 2026, DPHHS will have a hold harmless period for community engagement requirements. During these months, applications will be reviewed for compliance with community engagement requirements, but applicants will not be denied coverage for noncompliance with the new requirements as long as they meet all other conditions of eligibility.
Starting in October 2026, the hold harmless period will end, and noncompliance with community engagement requirements will be enforced with denial and disenrollment.
The benefits of the hold harmless period include:
- Additional time for new applicants and existing clients to become familiar with the requirements, with no adverse action taken.
- A three-month period for DPHHS to evaluate operational and systems processes and make small adjustments if needed before adverse actions are taken.
- Opportunity for DPHHS to collect data on implementation(e.g., use of exclusions, processing times) and make data-informed changes to policy decisions and the implementation approach, if needed.
Who has to follow the new community engagement requirements?
Adults ages 19-64 who are part of Montana’s Medicaid Expansion program. These individuals must either meet the 80-hour requirement through community engagement activities or qualify for an exclusion.
Who is in the “Medicaid Expansion population”?
This refers to adults who are eligible for Medicaid under the Affordable Care Act expansion (income up to approximately 138% of the federal poverty level).
What are the impacts to Presumptive Eligibility (PE)?
Beginning July 1, 2026, Qualified Entities must assess PE applicants who are eligible for coverage under Medicaid Expansion for community engagement requirements. PE determinations for community engagement requirements are based on applicant attestation (i.ge., QEs do not verify documentation or work hours – Montana Department of Public Health and Human Services will verify later at full application). Additional information and resources can be found on the Presumptive Eligibility webpage.
How do I know if I am excluded?
Some people do not have to follow the community engagement requirements. This is called being excluded. You might be excluded if you are in the following groups:
- American Indian/Alaska Natives
- Caregivers for children under age 14 or persons with disabilities
- Children aged 18 or younger
- Former Foster Youth under age 26
- Inmates of a public institution or incarcerated in the last three months
- People with a medical condition or health needs that impact ability to work or do other community engagement activities
- People who meet TANF work requirements, or receive SNAP and are subject to SNAP work requirements
- People in a drug or alcohol rehabilitation or treatment program
- Women who are pregnant or postpartum (up to 12 months)
- People eligible for Medicare
- Veterans with a total disability rating
- People experiencing the following short-term hardships:
- Receive inpatient hospital services, nursing facility services, services in an intermediate care facility for individuals with intellectual disabilities, inpatient psychiatric hospital services, or similar services
- Reside in a county where there is an emergency or disaster declaration
- Reside in a county that has an unemployment rate greater than the lesser of 8 percent or 1.5 times the national unemployment rate
- You or your dependent must travel outside of your community for an extended period to receive medical services necessary to treat a serious or complex medical condition that are not available within the community you live in
How is “medically frail” defined?
CMS Definition of Medically Frail
The Centers for Medicare & Medicaid Services (CMS) defined medically frail as follows in the Interim Final Rule with Comment (IFC) released on June 1, 2026:
We are defining a medically frail individual at § 435.554(c)(5) as an individual whose physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement in this subpart and who is blind or disabled (as defined at section 1614 of the Act); with a substance use disorder (SUD); with a disabling mental disorder; with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living (ADLs); or with a serious or complex medical condition. Individuals only need to fit within one of these categories to qualify for the medically frail exclusion to the community engagement requirement.[1]
[1] Federal Register: Medicaid Program; Community Engagement Requirement for Certain Individuals; Interim Final Rule with Comment Period
In the IFC, CMS provides some guardrails and suggestions around the five categories of medically frail, but did not provide specific definitions for substance use disorder, disabling mental disorder, physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living (ADLs), and with a serious or complex medical condition. For plain language communications, the Department refers to medically frail as “a medical condition or health needs that impact ability to work or do other community engagement activities.”
Montana’s Approach to Medically Frail
The Montana Department of Public Health and Human Services (DPHHS), led by the Department’s State Medical Officer, developed the following approach. Please note that DPHHS still expects additional guidance and clarification from CMS regarding medically frail. This approach will be updated as needed by the Department.
Conditions that Qualify as Medically Frail
| Description | Medically Frail Category |
|---|---|
| Adult failure to thrive | Disabling Mental Disorder |
| Age-related debility | Disabling Mental Disorder |
| Alcohol use disorder | Substance Use Disorder |
| Alcoholic hepatic disease/cirrhosis | Serious or Complex Medical Condition |
| Amputation — acquired absence of limb (upper/lower extremity, various levels) | Physical, Intellectual, or Developmental Disability |
| Amyotrophic lateral sclerosis (ALS) | Serious or Complex Medical Condition |
| Bed confinement; need for assistance; limited mobility | Physical, Intellectual, or Developmental Disability |
| Brain injury — traumatic intracranial injury (acute, initial encounter) | Physical, Intellectual, or Developmental Disability |
| Brain injury sequelae — personality/behavioral disorders due to known physiological condition | Physical, Intellectual, or Developmental Disability |
| Cancer | Serious or Complex Medical Condition |
| Cerebral palsy (spastic, dyskinetic, ataxic, mixed, unspecified) | Physical, Intellectual, or Developmental Disability |
| Chronic Kidney Disease stage 5 or ESRD | Serious or Complex Medical Condition |
| Chronic obstructive pulmonary disease (COPD) | Serious or Complex Medical Condition |
| Cognitive impairment — mild neurocognitive disorder due to known physiological condition | Disabling Mental Disorder |
| Creutzfeldt-Jakob disease | Serious or Complex Medical Condition |
| Cystic fibrosis (pulmonary manifestations, meconium ileus, other complications) | Serious or Complex Medical Condition |
| Delusional disorders | Disabling Mental Disorder |
| Dementia (vascular, Alzheimer's, other) | Disabling Mental Disorder |
| Dependence on ventilator, wheelchair, oxygen, other devices | Physical, Intellectual, or Developmental Disability |
| Down syndrome (trisomy 21 nonmosaicism, mosaicism, translocation) | Physical, Intellectual, or Developmental Disability |
| Emphysema | Serious or Complex Medical Condition |
| Fragile X syndrome | Physical, Intellectual, or Developmental Disability |
| Gait and mobility issues | Physical, Intellectual, or Developmental Disability |
| Heart disease — ischemic heart disease (angina, MI, chronic ischemic, other) | Serious or Complex Medical Condition |
| Heart failure; hypertensive heart/CKD | Serious or Complex Medical Condition |
| Hemophilia (A, B, C) and other hereditary coagulation defects | Serious or Complex Medical Condition |
| History of falling | Physical, Intellectual, or Developmental Disability |
| HIV/AIDS — human immunodeficiency virus disease | Serious or Complex Medical Condition |
| Huntington's disease | Serious or Complex Medical Condition |
| Major depressive disorder | Disabling Mental Disorder |
| Multiple sclerosis | Serious or Complex Medical Condition |
| Muscle atrophy, weakness, sarcopenia | Physical, Intellectual, or Developmental Disability |
| Muscular dystrophy (Duchenne, Becker, limb-girdle, facioscapulohumeral, other) | Physical, Intellectual, or Developmental Disability |
| Opioid use disorder | Substance Use Disorder |
| Other non-mood psychotic disorders (brief psychotic, shared psychotic, other) | Disabling Mental Disorder |
| Panic disorder | Disabling Mental Disorder |
| Parkinson's disease | Serious or Complex Medical Condition |
| Prader-Willi syndrome | Physical, Intellectual, or Developmental Disability |
| Pressure ulcers | Physical, Intellectual, or Developmental Disability |
| Pulmonary fibrosis | Serious or Complex Medical Condition |
| Respiratory failure | Serious or Complex Medical Condition |
| Sarcoidosis (pulmonary, lymph nodes, skin, other and combined organs) | Serious or Complex Medical Condition |
| Schizophrenia (paranoid, disorganized, catatonic, undifferentiated, residual, other) | Disabling Mental Disorder |
| Schizotypal disorder | Disabling Mental Disorder |
| Sickle cell disease (Hb-SS, Hb-SC, sickle-cell thalassemia, and other types) | Serious or Complex Medical Condition |
| Spina bifida (cervical, thoracic, lumbar, sacral; with/without hydrocephalus) | Physical, Intellectual, or Developmental Disability |
| Spinal cord injury sequelae — paraplegia, quadriplegia, other paralytic syndromes | Physical, Intellectual, or Developmental Disability |
| Spinocerebellar ataxias (early-onset, late-onset, X-linked, other hereditary) | Serious or Complex Medical Condition |
| Stimulant use disorder | Substance Use Disorder |
| Thalassemia major (beta thalassemia / Cooley's anemia) | Serious or Complex Medical Condition |
| Trauma disorders — PTSD, acute stress reaction, adjustment disorders | Disabling Mental Disorder |
| Viral hepatitis (chronic hepatitis B, C, and other chronic viral hepatitis) | Serious or Complex Medical Condition |
| Weakness, malaise, fatigue | Physical, Intellectual, or Developmental Disability |
| Weight loss, underweight, cachexia | Disabling Mental Disorder |
Verifying Medically Frail Status
DPHHS accepts provider documentation or self-declaration to verify medically frail status at both application and redetermination. The self-declaration form is included on Page 4 of Appendix B: Community Engagement Exclusion Form. Earlier communications from the Department stated that self-declaration was only allowable at application; however, new guidance from CMS has shifted the Department’s approach, and self-declaration is allowable at both application and redetermination. The Department is currently developing an interface that will connect with existing medical claims data to evaluate medically frail status for existing and some former clients. This interface will launch in the fall. More information about this change and ways to request an exclusion for a condition not included in Montana’s existing medically frail framework will be communicated at that time.
If I am a parent of someone with a disability, do I have to follow the community engagement requirements?
If you are the parent of a person with a disability who requires your care, you do not have to follow the new community engagement requirements. This is true no matter how old your child is.
I am in the Montana Medicaid for Workers with Disabilities program. Do the community engagement requirements apply to me?
No. If you are already in this program, you do not need to worry about these new requirements. You just need to keep following the same rules you already use for your job and your income. Nothing has changed for you.
Are older adults subject to the community engagement requirements?
No, only Medicaid Expansion adults aged 19-64.
Are people receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) subject to the new rules?
No. If you receive SSI or SSDI disability payments, you do not have to follow the community engagement requirements. People with disabilities do not have to meet the new requirements.
How do I show I meet the community engagement requirements or have an exclusion?
DPHHS has a verification matrix that shows what proof is needed for each qualifying activity and exclusion. You will need to provide documents or other proof needed to verify the specific activities and exclusions that apply to you. Please reference the verification matrix for additional information.
How often do I need to show verification of community engagement activities or exclusion from those activities?
When demonstrating compliance for community engagement activities:
- At application, you must show that you met CE requirements for the month prior to your application (a one-month lookback).
- At redetermination, you must show that you met CE requirements for three months of your redetermination review period (a three-month lookback - does not need to be three months in a row).
When demonstrating that you have an exclusion:
- Most exclusions are evaluated at the month of application or redetermination.
- Some exclusions (people eligible for Medicare, people incarcerated within the past three months, and people experiencing the established short-term hardships) are evaluated based on the lookback periods above.
How does someone with seasonal income verify they met the community engagement requirements?
Members with seasonal income can meet the community engagement requirement by completing 80 hours in a month. Members can show they met this requirement by checking if their average monthly income over the past 6 months is at least $7.25 per hour for 80 hours. If they do not complete 80 hours of seasonal work, they can combine activities such as volunteering and school to reach the monthly total.
How does a student verify they met the community engagement requirements?
Members enrolled in a college, career and technical education program, or high school/GED program and attending at least half-time can meet the requirement by providing a transcript or school schedule showing half-time or full-time attendance. If the transcript does not specify attendance level, 13 hours per month will count for each 1 credit completed. If needed, students can also combine school with other activities, such as work or volunteering, to meet the monthly requirement.
Once I’m determined eligible for Medicaid, how often am I required to redetermine my coverage?
Beginning January 2027, most people must redetermine coverage every six months. At that time, to keep your health coverage, you must show that you still qualify and meet the community engagement requirements. This does not apply to American Indian/Alaskan Natives, as they must redetermine coverage every 12 months.
What happens if I can’t verify that I’ve met the community engagement requirements?
From July through September 2026, DPHHS will review community engagement for applications and redeterminations, but people will not be denied coverage or disenrolled for not meeting the requirement during this time.
Starting in October 2026, DPHHS will continue to review community engagement for applications and redeterminations, and people who do not meet the requirement may be denied coverage or disenrolled.
Can individuals appeal eligibility decisions related to community engagement requirements?
Yes. Members can appeal decisions by following the instructions on their Notice of Adverse Action. Montana’s appeals process will be outlined in official notices and on the DPHHS website.
How will notice and communication work?
DPHHS will send updated notices indicating whether members need to meet community engagement requirements, how they can comply, and how to verify they have completed them. Members are encouraged to create an account on the Self Service Portal and opt-in to email communications.