HELENA — When President Donald Trump signed HR 1 – also known as the “One Big Bill” – into law last week, it formalized some big changes ahead for Medicaid programs, including in Montana.
Under the new law, the federal government is going to require states to put in work requirements for people on Medicaid expansion by the end of 2026. But leaders with the Montana Department of Public Health and Human Services said Tuesday they don’t want to wait that long to begin implementing Montana’s “community engagement” requirements.
“From our perspective, this cannot wait,” said DPHHS Director Charlie Brereton, during a meeting of the Montana Legislature’s Children, Families, Health and Human Services Interim Committee.
(Watch the video for more on how Montana's Medicaid program could be changing.)
The committee held its first meeting of the 2025-26 interim at the State Capitol Tuesday. Brereton and other DPHHS came to introduce themselves to lawmakers and to deliver an update on how they’re adjusting to the changes in HR 1.
“Given that the bill was just signed on July 4 – so last Friday – we're still very much in the process as a department of moving through the bill and figuring out the exact requirements that actually ended up in the final legislation,” said Rebecca de Camara, the state Medicaid director for DPHHS.
But while leaders may still be working out the details, it’s already clear the law means big changes for Medicaid. It’s going to require recipients to confirm their eligibility every six months instead of once a year, it will expand “cost sharing” payments that some Medicaid expansion recipients will need to make and it will mandate people on Medicaid expansion work or do other approved activities 80 hours a month.
Since 2019, Montana’s Medicaid expansion law has already called for recipients to do that amount of work, education, training, volunteering or other forms of community engagement. That language remained when the state renewed Medicaid expansion this year. However, Montana never implemented the requirements because the federal government didn’t approve a waiver to allow it.
Now, the situation at the federal level has changed. DPHHS announced this week that they're submitting a new waiver request to the Centers for Medicare and Medicaid Studies.
Leaders said they’re still working on some of the details for the waiver proposal. For example, the state and federal laws each call for some recipients to be exempted from work requirements – but they have different criteria who’s included.
De Camara said DPHHS is working with a consultant on aligning the state and federal requirements. She said there’s a lot of overlap on community engagement, but that the two models do have significant differences when it comes to cost sharing.
DPHHS plans to release its full plans for the waiver next week, but they’re already accepting public comment.
“Members of the public, legislators, providers and healthcare stakeholders not only have an opportunity to weigh in on the draft waiver once that is issued on July 18th, but also to weigh in right now as we are actively drafting and designing that waiver,” Brereton said.
The department will take public comment by email or by mail. You can find more information on the proposed waiver by going to help.mt.gov.
Some questioned the need to move forward with a waiver request at this time. Heather O’Loughlin, executive director of the Montana Budget and Policy Center, said if all states are going to have to implement community engagement requirements, there's almost no reason for Montana to seek a waiver.
“I think we're a little concerned about moving forward with the waiver proposal before we have a full sense of what the implications will be of the federal law,” she said.
But Brereton said DPHHS considers they have a legislative mandate to move forward as quickly as possible.
“We do not want to wait until CMS promulgates rules or issues regulatory guidance on the new HR 1 requirements,” he said.
DPHHS plans to submit their waiver request to the federal government in early September.
“We know it's moving fast, but we do have a history in Montana of pursuing community engagement and cost sharing with CMS, so feel like this is a reasonable timeline for us to follow,” said de Camara.
