Montana’s Medicaid Work Requirement Threatens Coverage for Homeless Residents

In the spring, the federal government finalized regulations that require Medicaid recipients to demonstrate participation in work, volunteering, or schooling to retain benefits. States must begin eligibility checks by the following January, and Montana plans to start enforcing the rule in October. The regulations exempt people with disabilities, those over 64, pregnant individuals, and Native Americans, but they do not automatically exempt people who are homeless. Montana’s earlier proposals had sought to include homelessness, domestic-violence survivors, and caregivers of hospitalized relatives as exemptions, yet the federal list does not allow those categories.

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Tywon Pugh, a 46-year-old with seizure disorder who became homeless after his wife’s death, illustrates the personal stakes. He relies on Medicaid for seizure medication and for an addiction-treatment program that currently has a waitlist. Under Montana’s plan, anyone not automatically exempt must submit proof of exemption within 30 days, a daunting task for someone who often lacks stable housing, documents, or transportation to medical appointments.

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CMS administrator Mehmet Oz framed the rule as a “path to prosperity,” emphasizing the goal of encouraging employment among Medicaid recipients. The Centers for Medicare & Medicaid Services confirmed that states must adhere to the federal exemption list, declining to comment further.

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The Department of Housing and Urban Development reports a 27 % rise in U.S. homelessness from 2013 to 2025, with about 746,000 people experiencing homelessness last year. In 2023, 55 % of patients served by the nation’s roughly 300 Health Care for the Homeless programs were enrolled in Medicaid. The Congressional Budget Office projects that the work-requirement rules could increase the uninsured population by more than 5 million by 2034.

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• “They called me a 'liability to the job site,'” — Tywon Pugh

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• “When she died, my whole base was depleted,” — Tywon Pugh

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• “My Medicaid is still active, but when are they gonna cut that off from me?” — Tywon Pugh

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• “You can't really worry about getting paperwork done when you don't know where you're eating today,” — Dustin Goss, case manager, Samaritan House

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• “It's just that if I don't make the effort at changing, it ain't gonna happen and I'm gonna end up found on the side of the road somewhere,” — Tywon Pugh

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