What Comes Next?
Earlier this month, the “Big Beautiful Bill” (HR1) became federal law, triggering sweeping changes to major public programs, including Medicaid, SNAP, and the ACA Marketplace. These changes are expected to reshape how millions of Americans – tens of thousands of Montanans- access vital supports. While states have until December 31, 2026 to comply, Montana’s Department of Public Heath and Human Services (DPHHS) is moving quickly by planning to submit a Medicaid 1115 Demonstration Waiver by September 2, 2025. This waiver will detail DPHHS’ plan for implementing community engagement requirements (work requirements) and cost-sharing requirements (co-pays).
Importantly, DPHHS is requesting feedback now, before the full draft is released, giving us a key opportunity to help shape the waiver early on in the process. BHAM recommends submitting any pre-draft comments no later than July 16, 2025. The full waiver draft will be published on the DPHHS website on July 18, 2025, at which point the formal 30-day public comment period will begin. See details below for more information on the public comment process.
What’s Changing and Why It Matters
These policy shifts will represent significant changes to long-standing policies and processes. Individuals who have been covered for years may find themselves newly ineligible, while others, who previously didn’t have to submit paperwork or pay out-of-pocket, may now need to navigate new systems. These changes will inevitably bring confusion and new challenges to individuals and their families, as well as service providers and organizations.
Both the federal government and Montana DPHHS are still working to define key parts of these changes, such as who will be exempt, what activities will count as “work,” and how cost-sharing will be implemented. While there is general federal guidance around exemptions, state and federal agencies are still determining how those categories will be defined and applied and what documentation will be required for verification.
The list below provides a general preview of what’s coming with more clarity expected over the summer and fall.
What to Expect:
- Medicaid Eligibility Reviews Every 6 Months
- Redeterminations will now be required every six months (previously every 12-months), which may lead to increased coverage loss – similar to issues seen during the 2023 Medicaid Unwinding/ Redetermination. However, a new Community Assistance Portal is being developed that should help to streamline the renewal process.
- Reduced Retroactive Coverage
- Medicaid Expansion enrollees will only receive one month of retroactive coverage (down from three months). This could lead to an increase in uncompensated services for new clients, clients experiencing a crisis, or clients who did not know they lost insurance coverage.
- Traditional Medicaid will receive two month of retroactive coverage.
- Medicaid Expansion enrollees will only receive one month of retroactive coverage (down from three months). This could lead to an increase in uncompensated services for new clients, clients experiencing a crisis, or clients who did not know they lost insurance coverage.
- New Monthly Copays for Some Enrollees
- Medicaid enrollees over 100% of the federal poverty level (FPL) may be required to pay monthly copays for certain services. While many behavioral health and primary care services are expected to be exempt, specific rules are still being developed.
- Work Requirements (Medicaid)
- Adults ages 19-64 must complete 80 hours/month of work, volunteering, or schooling. Behavioral health treatment may count, but the final definitions and verification processes are still being defined.
- Expanded Work Requirements (Supplemental Nutrition Assistance Program/SNAP)
- Adults under 65 will need to verify 80 hours/month of activity (work, volunteering, school, treatment) to maintain food assistance (food stamps).
- This new rule also eliminates some current exemptions (e.g., veterans, people experiencing homelessness, etc.).
- On a broader level:
- Changes to provider tax policy may reduce funding for rural hospitals and clinics, potentially increasing closures and putting more pressure on urban hospitals with high Medicaid populations.
- Major changes to the ACA Marketplace will make it harder to maintain coverage, including new verification requirements, reduced eligibility for premium credits, increased risk of repayment if income changes mid-year, and the expiration of the enhanced subsidies after 2025.
One important relief: Earlier this year, there was concern that the federal match rate (FMAP) for Medicaid Expansion could drop below 90%, which would have triggered a special legislative session in Montana to determine the future of the program. The good news is, the FMAP was not lowered. This means Montana’s trigger law will not be activated, and a special session is not expected.
KFF: Health Provisions in the 2025 Federal Budget Reconciliation Bill
SHVS: House Energy and Commerce Committee Reconciliation Legislation Proposes Mandatory Work Requirements in Medicaid
Verywell Health: New Law Slashes Healthcare Spending and Cuts Coverage—What That Means For You
How to Prepare Clients and Your Team
Again, many of these changes are not expected to take place immediately. However, Montana may end up moving faster than the federal deadlines.
Preparing Clients & Families
- Start conversations now. Most people don’t know changes are coming or how they may be affected.
- Acknowledge uncertainty and fear. Changes that impact someone’s health and stability are stressful.
- Educate clients and their natural supports (like family or caregivers) about changes and what may be required (e.g., documentation, verification, tracking hours, etc.). Start creating a plan.
- Clarify roles and responsibilities. Identify who on the treatment team can assist with renewals, exemption documentation, and administrative tasks.
- Start collecting and keeping thorough documentation of health, diagnoses, and employment/ volunteering/ treatment participation.
Preparing Your Organization & Team
- Normalize uncertainty. These changes will affect staff too. Make space for questions and remind your team: our role isn’t to fix it all… it’s to support and navigate through the changes together.
- Review and update your organization’s intake and renewal workflows.
- Include eligibility checks at intake and prep for 6-month Medicaid renewal cycles.
- Collecting documentation to verify or support a client’s health conditions, diagnoses, work activities or exemptions, etc.
- Client communication and outreach strategies.
- Monitoring and tracking early warning signs like no-shows, coverage loss, or client confusion.
- Train staff on the proposed exemption categories and how to ensure documentation is thorough to support exemptions and continuity of care.
- Build partnerships with enrollment specialists and community supports
- Stay current on Montana’s specific requirements and timelines.
Taking Action: Submit Public Comment, Ensure Your Voice is Fully Represented
DPHHS is collecting input now to help shape the design of Montana’s 1115 Demonstration Waiver before it’s submitted to the federal government in September.
“I encourage all Montanans to weigh in and participate in this public process,” -DPHHS Director Charlie Brereton
There are two opportunities for submitting feedback:
- DPHHS is requesting public input now, before the full draft is released on July 18. Pre-draft comments can help to proactively shape the design of the waiver draft.
- BHAM recommends submitting any pre-draft comments to DPHHS by July 16.
- What to Include in Your Pre-Draft Comments:
- What you do or don’t want to see in the waiver
- Concerns about client impact, feasibility, or unintended consequences
- Suggestions to improve access, workflow, flexibility, or fairness
- The full draft will be released on July 18 on the DPHHS HELP webpage, followed by a formal public comment period ending on August 18, 2025.
Submit comments to dphhscomments@mt.gov with the subject line of “HELP Demonstration Waiver”.
DPHHS Press Release: DPHHS Seeks Public Comment on Proposed Community Engagement, Cost Sharing
Public Notice of Section 1115 Waiver
Please reach out to me if there is anything you need. When we work together, we can solve all the problems out there!
Stay safe. Stay healthy.
Sierra
info@bhamt.org