Frequently Asked Questions
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 introduced a new community engagement requirement 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 requirement requires non-excluded adults on Medicaid Expansion, aged 19-64, to participate in community engagement activities to keep their health coverage.
The community engagement requirement includes:
- 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 with a not-for-profit organization
- Participating in an approved state or federal workforce training or job readiness program
- Going to school
The community engagement requirement applies to you if:
- You are between the ages of 19-64.
- You are covered under the Medicaid Expansion (low-income adults).
- You are not excluded.
Montana went live with implementation of the community engagement requirements for the Medicaid Expansion population on July 1, 2026. This means that:
- For new applicants: All new applications for Medicaid Expansion on and after July 1, 2026, will be required to meet the community engagement requirement 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 the community engagement requirement.
What is the “hold harmless” period?
From July through September 2026, DPHHS will have a hold harmless period for the community engagement requirement. During these months, applications will be reviewed for compliance with the community engagement requirement, but applicants will not be denied coverage for noncompliance with the new requirement as long as they meet all other conditions of eligibility.
Starting in October 2026, the hold harmless period will end, and noncompliance with the community engagement requirement 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 requirement, 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 meet the new community engagement requirement?
Adults aged 19-64 who are part of Montana’s Medicaid Expansion program must meet the community engagement requirement. 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 the community engagement requirement. PE determinations for the community engagement requirement 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 individuals are excluded from the community engagement requirement. Individuals who meet an approved exclusion are not required to meet the community engagement requirement for one or more months.
There are two different ways you may be excluded from the community engagement requirement, and they work differently:
- If you are a specified excluded individual, the requirement does not apply to you at all.
- If you have an exception or a short-term hardship, you are treated as meeting the requirement only for the months that the exception or hardship applies to you. At redetermination, if you cannot show that you had an exception or short-term hardship for three of the months since your last redetermination, you will need to meet the community engagement requirement through approved activities to keep your Medicaid coverage.
Specified Exclusions apply to your current situation. You may be excluded if one or more of the following options apply to you at the time of your application or redetermination:
- American Indian/Alaska Native
- Children aged 18 or younger
- Former Foster Youth under age 26 who was on Medicaid and in foster care when they turned 18
- Inmate of a public institution (e.g., jail, prison)
- People with a medical condition or health needs that impact their ability to work or do other community engagement activities (for more information on this exclusion, please reference the FAQ page)
- Parent, guardian, caretaker relative, or family caregiver of a dependent child under age 14 or a disabled individual
- People in a drug or alcohol rehabilitation or treatment program
- People who meet TANF work requirements, or receive SNAP and are subject to SNAP work requirements
- Women who are pregnant or postpartum (up to 12 months)
- Veterans with a total (100%) disability rating
Exceptions and short-term hardships may fulfill part or all of the community engagement requirement for the months that they apply to you:
- People eligible for Medicare
- People incarcerated in the last three months
- People experiencing the following short-term hardships:
- Receiving inpatient services
- Residing in a county with an emergency disaster declaration
- Residing in a county with high unemployment (Note: Montana will not be implementing the high unemployment exception at this time)
- Person or dependent who must travel outside of their community for medical services for a serious or complex medical condition
At application, you must show that an exception or short term hardship applied for the month before your new application.
At redetermination, you must show that an exception or short-term hardship applied for at least 3 months since your last redetermination. The months do not need to be consecutive. If you have an exception or short-term hardship for one or two months, you must complete the remainder of the community engagement requirement by reporting qualifying activity hours.
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 requirement?
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 requirement. 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 requirement?
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 requirement. People with disabilities do not have to meet the new requirement.
How do I show I meet the community engagement requirement 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 the CE requirement or had an exclusion for the month prior to your application.
- At redetermination, you must show that you met the community engagement requirement or had an exclusion for three months of your redetermination review period (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 requirement?
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 requirement?
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 requirement. 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 requirement?
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 requirement?
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 the community engagement requirement, 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.