Tribal health leaders during a Tuesday public consultation questioned and criticized Montana’s move toward Medicaid work requirements and premiums for the low-income health coverage plan — a process the state health department is kickstarting months ahead of the schedule laid out in a Republican-backed domestic policy bill signed by President Donald Trump on July 4.
Although Native Americans are exempted from many of the new state and federal requirements, representatives from tribal governments and Urban Indian Organizations raised red flags about the risks of increased bureaucracy during the consultation. Several leaders expressed concerns that enrolled tribal members and health clinic patients may end up ensnared by administrative red tape and urged the state health department to take a slower and more methodical approach to developing its new system.
“It seems like we’re being a little premature with this anyways,” said Joel Rosette, CEO of the Rocky Boy Health Center located on the Rocky Boy’s Reservation in north central Montana. “We’re a year ahead and there seems to be more questions than answers.”
State health officials, including Montana Medicaid Director Rebecca de Camara, repeatedly told tribal counterparts that their input was welcome, even if details about the new requirements don’t yet exist.
“I think that we have this question across the board, for how we’re going to have folks demonstrate that they’re in compliance,” de Camara said, referring to work requirements and exemptions. “So [we’re] still very much working through that process.”
Gov. Greg Gianforte’s appointed leadership in the Department of Public Health and Human Services announced in July that the state would amend its federally approved Medicaid plan to include community engagement requirements — such as paid work, community service or educational programs — and premiums for certain enrollees.
State officials say the proposed revision, conducted through a Section 1115 Demonstration Waiver, is in line with Montana’s 2019 law that added work requirements to the Medicaid expansion program and would complement the provisions of H.R. 1, the sweeping federal budget bill.
Montana’s draft proposal estimates that 17.5% of the current Medicaid expansion population will lose coverage through the implementation of work requirements and an additional 1.5-2.5% of enrollees will be disenrolled because of premiums. If the waiver is not approved, the state plan projects that the Medicaid expansion program would have 22,500 more people enrolled between 2026 and 2027.
Native Americans in Montana make up a disproportionate share of Medicaid enrollees compared to the statewide population. Under the state’s Medicaid expansion program, the uninsured rate for Native Americans between the ages of 19-64 has dropped significantly. The current Medicaid reimbursement model has also become a financial cornerstone for many tribal and urban health programs operating outside the budget-strapped and backlogged Indian Health Service system, allowing them to expand their workforces and services.
As tribal leaders on Tuesday repeatedly asked what the Native American exemptions would look like in practice, state health department officials offered little guidance.
While the department currently asks individuals to check a box indicating whether they are Native American, DPHHS Human Services Executive Director Jessie Counts said, “it’s not clear if we’re going to continue to utilize that process” to verify Native American exemptions.
Rosette of Rocky Boy Health Center also advocated for the overall application process to be simplified, saying its “cumbersome” nature could cause people to lose coverage, despite being eligible.
Counts suggested that, while a simplified verification process could help people navigate new requirements, the federal provisions of H.R. 1 might take precedent.
“I don’t believe right now that, federally, there is a simplified process that’s available to us,” Counts said.
Several tribal leaders also questioned how tribal health departments, Urban Indian Organizations and the state would handle short-term exemptions from work requirements, including for people experiencing domestic violence and homelessness.
“How is the state going to work with folks to ensure these exemptions get to the right people at the right time?” Rosette asked. “… Has that been thought through how that’s going to work?”
While Counts said there are existing models for similar exemptions, de Camara said the process has not been developed “in any detail.”
Given the vague implementation plans, Rosette urged the department to take a slower approach, saying the lack of clarity would be burdensome both for individuals seeking care and for tribal health organizations.
“To me, this means more of the people that need to be on these Medicaid and Medicaid expansion [are] going to drop off because they’re the ones that aren’t going to sit there and do a 30-page application,” he said. “So they’ll come into our facility with no coverage, and then we’re going to try to figure it out. So to me, there’s a lot more work that needs to be done.”
Many tribal health officials pointed to the recent difficulty of navigating Medicaid “unwinding,” the state health department’s monthslong effort launched in 2023 to verify the eligibility of enrollees for the first time since the COVID-19 pandemic. Medicaid beneficiaries and their health providers across the state were plagued by long phone wait times, paperwork errors and unnecessary disenrollments, with nearly two-thirds of people removed from the program because of procedural errors rather than being found ineligible.
During that era of redetermination, Native American health experts and medical providers practicing in tribal communities repeatedly spoke up about how eligible enrollees were struggling to stay on Medicaid and communicate with overwhelmed state workers tasked with reviewing applications.
Helena Indian Alliance Executive Director Todd Wilson brought up some of those experiences, citing the bureaucratic mess as one reason for misgivings about how future work requirements and premiums will be implemented.
“There was all this confusion and chaos,” Wilson said. “I mean that’s part of the, I wouldn’t say frustration, but part of the unease for some of our ground-level folks is in that process. So hopefully the state gets that figured out.”
Counts replied by affirming that the state had learned “many lessons” from the eligibility review. When asked how the health department planned to increase staffing or otherwise prepare for the heavier workload on the horizon, Counts’ response was nonspecific.
“We are very aware that there will be extra requirements on the department, that it will require extra resources. And we’re really doing an analysis as we go through of what that’s going to look like,” Counts said. “A full implementation plan has not been developed at this point.”
Several tribal leaders suggested developing a formal partnership with the state to simplify the process going forward, and avoid some of the miscommunication and bureaucratic silos that cropped up in 2023.
“This would be the time where we look at collaboration, rather than creating these extra efforts,” Rosette said. “We want the same thing you do … I think if you talk to the tribes, there’s ways for us to help each other through these exemptions.”
Former DPHHS Tribal Relations Manager Lesa Evers said when Medicaid expansion began 10 years ago, the state worked with Indian Health Service and tribal health facilities to share eligibility and enrollment information.
“[Information was] dumped into our system, so we didn’t have to send 50,000 letters to people,” she said. “… It worked really well.”
Terra Branson-Thomas, senior policy advisor at Clause Law P.L.L.C. and a policy advisor for the Little Shell Tribe of Chippewa Indians, said tribal health departments and Urban Indian Organizations “could play a key role in identifying those who would be eligible for the exemption.”
“Tribes can really be a resource to the state and try to ease some of the administrative burdens for both our patients and the state,” she said.
The state health department has two other meetings scheduled to solicit public comment about the waiver proposal. An in-person and virtual meeting will be held in Helena on July 31 from 3-5 p.m. Another virtual-only meeting is scheduled for Aug. 1 from 3-5 p.m. Agendas, directions and virtual participation links are available on the DPHHS website.
