CurrentMontana Department of Public Health & Human ServicesPolicy COMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy
COMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy
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Governs community engagement (work/education/volunteer) requirements, exceptions, exclusions, verification, redetermination, and penalties for Montana ACA Medicaid Expansion (HELP Act) applicants and enrollees aged 19–64; identifies who is exempt or excepted and how compliance is verified.
Policy Summary
PayerMontana Department of Public Health & Human Services
PolicyCOMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy
Policy CodePolicy COMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy
Change TypeNo material change
Effective DateJuly 1, 2026
Next Review Date
Key ActionVerify community engagement, exceptions, and exclusions using data matches or member-provided verification and collect supporting documentation; notify members of noncompliance and allow 30 days to demonstrate compliance before denial or closure.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
80 hrsmonthly minimum
6 monthsredetermination cadence
30 daysgrace period
7/1/2026effective
1m/3mlookback periods
Community Engagement Requirements and Exceptions
Community engagement criteria, exceptions, exclusions, verification, and consequences
Covered when ALL of the following nested criteria and rules are applied to determine compliance with community engagement requirements, applicable exclusions and exceptions, verification methods, redetermination timing, and consequences for noncompliance.
Standard community engagement requirement: Members aged 19–64 must participate at least 80 hours per month in qualifying community engagement activities or earn the equivalent of 80 hours at the federal minimum wage per month; combinations of activities are allowed; household income is used when determining compliance.
Qualifying activities (ONE or more)
- Work: Paid work equal to 80 hours x federal minimum wage, including unpaid work that is part of a trial period or unpaid internships to gain job experience; in-kind compensation (housing, meals, utilities) may count with verification.
- Community service: Unpaid volunteer work (including court-mandated service) performed with a public or nonprofit organization where hours are structured and verifiable.
- Workforce training/job readiness: Participation in State of Montana workforce training, registered apprenticeships, internships, or job readiness programs.
- Education: Enrolled at least half-time in secondary, college, or vocational school; verified credit hours may be converted to allowable community engagement hours. Independent study or unmonitored self-paced online courses generally do not qualify unless program can monitor and document hours.
Specified exclusions (if met, member is not subject to requirement)
- American Indian or Alaska Native or determined eligible for Indian Health Services.
- Veteran with a total disability rating.
- Parent, guardian, caretaker relative, or family caregiver of dependent children under 14 years, or of a disabled person (caregiver rules apply; see caregiver node).
- Pregnant or entitled to postpartum coverage (up to 12 months after delivery).
- Currently incarcerated.
- Enrolled in a substance use disorder treatment program.
- Medically frail (see medically frail node).
- Meeting program requirements for TANF.
- Meeting program requirements for SNAP.
- Former foster youth under age 26 who were in foster care and Medicaid at age 18.
Family caregiver rules (to qualify for exclusion)
- Caregiver qualifies if: (1) a relative providing primary care (may or may not live with the dependent child or disabled individual), (2) a parent/guardian/caretaker relative residing with the dependent child or disabled individual, OR (3) a non-relative/non-cohabiting caregiver who provides at least 80 hours per month of care and not on an incidental basis.
- Caregivers must verify hours and that the care recipient is a dependent child or a disabled individual; documented caregiving hours under 80 hours/month may be applied toward unpaid work to meet requirements.
Medically frail specifics
- Definition: Includes individuals who are blind or disabled per SSA, have an SUD (unless in treatment or in stable recovery 5+ years), have a disabling mental disorder, have physical/intellectual/developmental disability significantly impairing ADLs, or have a serious or complex medical condition (acute or chronic) that impacts ability to meet the 80 hours/month requirement.
- SUD note: Individuals in an SUD treatment program are excluded; those not in stable recovery (under 5 years) may be considered medically frail.
Exceptions (lookback evaluation)
- Mandatory exceptions (evaluated in lookback month(s) at application and redetermination): under age 19; entitled to or enrolled in Medicare Part A or B; eligible under another eligibility group (e.g., PCR, SSI); incarcerated at some time in the last three months; specified excluded individuals during the lookback month are treated as mandatory exceptions for the months the exclusion applied.
- Short-term hardship exceptions (verified and evaluated in lookback month(s)): receiving inpatient institutional care (hospital, nursing facility, ICF/IID, inpatient psychiatric), necessary extended travel for medical services not available locally, residing in a federally declared emergency/disaster county, or residing in a county with unemployment greater than the lesser of 8% or 1.5x the national rate (some durations subject to federal approval). Verification of hardship and expected duration required.
Verification and lookback periods
- Lookback periods: 1-month lookback at application; 3-month lookback at redetermination.
- Verification methods: state will use data matches when available; if unable to verify, member must provide verification via supporting evidence (physician or facility statements, written statements, enrollment records in qualified programs, court documents, etc.). Ongoing exceptions or exclusions may require reverification at redetermination.
- Members may self-report compliance, exceptions, or exclusions online at apply.mt.gov, via the Public Assistance Helpline, by mail, fax, or in person.
Redetermination and timing
- General redetermination cadence: Members evaluated every 6 months to determine continued compliance, exceptions, or exclusions.
- American Indian/Alaska Native exception: AI/AN individuals are redetermined annually or when changes are reported (not subject to the 6-month redetermination requirement).
Non-compliance penalties and member notification
- If member does not meet community engagement requirements or qualify for an exception/exclusion at redetermination or when changes are reported, the member will be notified and given 30 days to demonstrate compliance.
- Failure to verify community engagement within the 30-day period will result in denial or closure of Medicaid coverage; closed individuals must reapply and demonstrate compliance, have an exception, or qualify for an exclusion to regain coverage.
Operational verification notes
- Verification of activities may include statements from physicians or facilities, written statements, enrollment records, court documents, and verification of in-kind work value and hours when applicable.
- Household income should be used when determining community engagement compliance (e.g., assessing equivalent earnings).
Engagement Threshold and Equivalencies
Monthly hours threshold
Monthly hours requirementMembers aged 19–64 must participate at least 80 hours per month in qualifying community engagement activities or earn the equivalent of 80 hours at the federal minimum wage.
Equivalent earnings optionEarning the equivalent of 80 hours at the federal minimum wage counts as meeting the monthly requirement.
Combination of activitiesA combination of qualifying activities (work, community service, training, school half-time, internships, apprenticeships) may be used to meet the 80-hour requirement.
Household income considerationHousehold income should be used when determining community engagement compliance.
Verification, Notification, and Administrative Responsibilities
Documentation Required
Verify participation and notify when documentation is required
Verify community engagement, exceptions, and exclusions using available data matches first; if state data matching cannot confirm status, obtain member-provided verification. Collect acceptable supporting documentation (for example: physician or facility statements, written statements, enrollment records in qualified programs, court documents). Allow members to self-report compliance, exceptions, or exclusions via apply.mt.gov, the Public Assistance Helpline, mail, fax, or in person. For redetermination use a 3‑month lookback (1‑month at application) and reverify ongoing exceptions or exclusions as needed.
- Use data matches when available; no further member verification required if data match confirms status.
- If no data match, require member verification with supporting documents (physician/facility statements, written statements, program enrollment records, court documents).
- Accept self-reporting through apply.mt.gov, Public Assistance Helpline, mail, fax, or in person.
- Apply 1‑month lookback at application and 3‑month lookback at redetermination; reverify ongoing exceptions/exclusions at redetermination.
Key Term Definitions
Community service — definition and examples
DefinitionCommunity service means unpaid work, completed voluntarily or because of a court mandate, within a structured program that directly benefits the community under the auspices of public or nonprofit organizations.
Where it occursMust be completed with a not-for-profit facility or organization where the public can participate; includes embedded program activities that develop skills necessary to complete community service.
ExamplesVolunteer work or work mandated by legal authority (court-ordered community service) performed for public or nonprofit organizations.
Non-qualifying formatsIndependent self-paced online study generally does not qualify; non-inperson programs must be able to monitor and document hours (e.g., virtual high school classes only if hours can be verified).
Medically frail — definition
Core definitionMedically frail includes individuals who are blind or disabled per SSA (section 1614), have a disabling mental disorder, have a physical, intellectual, or developmental disability that significantly impairs activities of daily living, or have a serious or complex medical condition.
Substance use disorderIndividuals with a substance use disorder who are in a treatment program are excluded from community engagement requirements; those not in treatment or not in stable recovery (less than 5 consecutive years) are considered medically frail.
Serious or complex condition detailsSerious/complex conditions include acute illnesses requiring specialized treatment to avoid death or permanent harm, and chronic illnesses that are life‑threatening, degenerative, potentially disabling, congenital, or require prolonged specialized care.
Impact on requirementA medically frail individual is excluded from meeting community engagement requirements if the condition impacts their ability to work or meet the 80 hours/month requirement.
Family caregiver — who qualifies
Who qualifiesAn adult family member or other individual with a significant relationship who provides primary care to a dependent child or a disabled individual may qualify as a family caregiver.
Relative caregiversRelatives who provide primary care may qualify for the community engagement exclusion whether or not they live with the dependent child or disabled individual.
Parent/guardian/caretaker relativeParents, guardians, or caretaker relatives residing with the dependent child or disabled individual qualify under caregiver rules.
Non-relative/non-cohabiting caregiversNon-relatives or caregivers not living with the care recipient must provide at least 80 hours per month of care that is not incidental (not babysitting) to qualify; documented caregiving hours may be applied to unpaid work if under 80 hours.
Verification requirementAll caregivers must verify hours provided and that the person receiving care is a dependent child or a disabled individual.
Policy Summary
PayerMontana Department of Public Health & Human Services
PolicyCOMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy
Policy CodePolicy COMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy
Change TypeNo material change
Effective DateJuly 1, 2026
Next Review Date
Key ActionVerify community engagement, exceptions, and exclusions using data matches or member-provided verification and collect supporting documentation; notify members of noncompliance and allow 30 days to demonstrate compliance before denial or closure.
SourceLink
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