to require proof that adult enrollees are working a certain number of hours or looking for work as a condition of receiving Medicaid expansion benefits, the Centers for Medicare & Medicaid Services has reversed course under Democratic President Joe Biden.

“CMS has communicated to [the Montana Department of Public Health and Human Services] that a five-year extension of the Medicaid expansion waiver will not include work/community engagement requirements,” health officials wrote in a Medicaid waiver amendment application out for public review.

It’s unclear what that means for the future of the Montana program. In 2019, Montana lawmakers approved extending the 2015 program — the Supreme Court made the Medicaid expansion provision in the Affordable Care Act optional for states — as long as it included work requirements. Those requirements were a key condition for the moderate Republicans who joined Democratic lawmakers to muster enough votes to pass the 2019 bill over the objections of conservative GOP legislators.

The state’s position officially remains that it wants “to condition Medicaid coverage on compliance with work/community engagement requirements,” according to the amendment application. If state negotiators are proposing an alternative, they have not disclosed it.

If CMS does not approve the waiver with the work or community engagement requirements, the state health department will operate Medicaid expansion according to what is approved and await legislative review of the program, said department spokesperson Jon Ebelt.

The Montana Medicaid expansion program is scheduled to end in 2025 if the legislature doesn’t renew it. State lawmakers meet every other year, giving them the 2023 and 2025 sessions to consider changes to the popular program, which enrolls 10% of the state’s population.

Meanwhile, Republican-led lawmakers and Republican Gov. Greg Gianforte’s administration have supported other measures designed to trim the Medicaid expansion rolls and defray costs, including raising the premiums some enrollees pay and ending a provision that allows 12 months of continuous eligibility regardless of changes in income. Those proposals are also pending federal approval, and it was in the state’s application for the 12-month continuous eligibility waiver that the status of the work requirement negotiations was disclosed.

In June, the number of Montanans enrolled in the expansion program for the first time in its 5½-year history. The program provides health insurance coverage to adults who earn up to 138% of the federal poverty level,

The negotiations between state and federal health officials involve what’s called a Section 1115 waiver amendment application to CMS, which is made when a state Medicaid program seeks to deviate from federal requirements. CMS’ deadline for acting on the application, originally submitted in 2019, was extended to Dec. 31, 2021, because of the covid-19 pandemic.

The Trump administration approved work requirement waivers in 12 other states, though no states are implementing those requirements, either because of the pandemic or lawsuits, (KHN is an editorially independent program of KFF.)

Since Biden took office, CMS has withdrawn the Trump administration’s approval of work requirement waivers

Asked to comment about the Montana negotiations, CMS officials said Medicaid is a lifeline for millions of Americans who would be put at risk by work requirements.

“The pandemic and uncertainty surrounding its long-term social, health, and economic effects exacerbate the risks associated with tying Medicaid eligibility to requirements that have been demonstrated to result in significant coverage losses and substantial harm to beneficiaries,” an unattributed CMS statement said.

Montana health department officials said in their waiver application that they expect negotiations with CMS to be finalized in the fall and the Medicaid waiver to be extended for five years starting in January. That Jan. 1, 2027, end date of the waiver, presumably without work requirements, would be subject to the state’s own 2025 sunset.

The 2019 state law granting a six-year extension to the Medicaid expansion included the condition that work and community engagement be part of it. The law states beneficiaries must work at least 80 hours each month or be engaged in a job search or volunteer work, unless they are exempt for specific reasons, such as pregnancy, disability or mental illness.

State Rep. Ed Buttrey (R-Great Falls), who sponsored both the 2019 bill and the 2015 bill that created the original Montana Medicaid expansion program, said lawmakers added the 2025 sunset so that they could assess and revise the program, if needed.

“So in a couple sessions we’ll have to take another look at the program and the federal rules and find out how things are performing and how we want to move forward.” Buttrey said.

He defended work requirements, saying the goal of Medicaid expansion has always been to create a healthy workforce to improve Montana’s economy.

State Rep. Mary Caferro (D-Helena) said work requirements can cause unnecessary hurdles for people who qualify for the Medicaid expansion program. She said that 7 in 10 Montanans who gained Medicaid coverage under the expansion are already working and that the rest can’t for various reasons, such as they are caregivers, have an illness or are going to school.

“Work requirements don’t make sense for our particular population,” Caferro said.

The disclosure of the ongoing work requirement negotiations was made in an application that seeks to eliminate 12-month continuous eligibility for Medicaid expansion beneficiaries plus a separate group of Medicaid beneficiaries with severe disabling mental illnesses.

Currently, those people are enrolled in the Medicaid expansion program for a full year regardless of changes in income or assets. The proposed change, included in the state budget passed by lawmakers earlier this year, would kick enrollees out of the program if their income rises — even if only temporarily because of a one-time payment or seasonal work.

The state also proposes increasing premium payments for certain expansion beneficiaries to up to 4% of their household income in the same waiver application that proposes work requirements.

Buttrey said the goal was to offset the costs of Medicaid so that the people benefiting from it bore some of the costs, and hopes CMS will approve the proposal.

for the state’s waiver applications is open until Aug. 31. A legislative committee is scheduled to meet Tuesday to review the proposals.

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in Montana requires its students who have finished their academic work to complete clerkships and clinical rotations to graduate, and then those graduates must be matched with residencies. WWAMI — an acronym of the five states participating in the program: Washington, Wyoming, Alaska, Montana and Idaho — uses hundreds of Montana physicians for that hands-on training, in addition to physicians in the other four states.

That’s why plans by the for-profit Rocky Vista University College of Osteopathic Medicine to build a campus in Billings and the nonprofit Touro College and University System to build an osteopathic medical school in Great Falls have WWAMI officials worried.

“The biggest concern that everyone has is around clinical resources,” said Dr. Suzanne Allen, vice dean of academic, rural and regional affairs for UW’s School of Medicine. “At some point, there’s not enough of those clinical resources to go around for everyone to have a good learning experience.”

The University of Washington is an allopathic medical school, whose graduates are doctors of medicine, while the proposed Montana schools would train doctors of osteopathic medicine. Both kinds of doctors are fully licensed physicians. The students study the same curriculum and participate in the same clinical training, but they take different licensing exams, and the schools are accredited by different panels: The for allopathic schools, and the for osteopathic schools.

Dr. Jay Erickson, assistant dean for regional affairs and rural health and assistant clinical dean for , criticized lax osteopathic school accreditation standards for creating a potential Montana medical student logjam that could affect his program.

“The LCME which accredits allopathic medical schools would never approve two new medical schools in a state of 1 million people with limited clinical teaching opportunities that are largely utilized by Montana WWAMI and the existing residencies,” Erickson said in an email.

, which has schools in Colorado and Utah, announced in May that the Commission on Osteopathic College Accreditation had approved its plan to build a Billings campus. The application by , which has campuses across the country, for a facility in Great Falls is set to be taken up at the commission’s August meeting.

Opening new medical schools would provide more slots to in-state students who might otherwise be rejected because of WWAMI’s thresholds. Montana WWAMI accepts only 30 students a year. In Alaska and Wyoming, it’s 20 students a year. In Idaho, it’s 40, and in Washington, it’s 160 divided between Seattle and Spokane. All WWAMI students must be residents of the state in which they apply.

Those classroom slots don’t necessarily guarantee more training opportunities in the field. Such work accounts for about half of a medical student’s education.

For the first two years, students in the WWAMI program receive classroom instruction at affiliated universities, such as Montana State University in Bozeman. Then in their third and fourth years, WWAMI students are required to complete clerkships and clinical rotations with doctors whom the program uses as clinical faculty, or teaching doctors, across the state.

About 230 WWAMI students from all five states participate in Montana clerkships as well as clerkships in the other four states. Other medical schools, including Idaho’s College of Osteopathic Medicine and the Pacific Northwest University’s College of Osteopathic Medicine, also use Montana for their students’ clinical training.

The worry of school officials and some of those teaching doctors is that the flood of students the two new medical schools would bring could lead to increased competition and be harmful to the hands-on education that clinical rotations are designed to provide.

Dr. KayCee Gardner, a 36-year-old WWAMI graduate, practices family medicine in Miles City and trains WWAMI students.

“I just hope with more medical schools being built that there will be enough teachers and enough places for them to get a good rotation and not just be standing in the back observing,” Gardner said.

Another point of concern is how the new Montana schools will affect residencies, which all medical school students must complete after graduating to become certified doctors. Residency placements are already very competitive, depending on the hospital and the specialty. WWAMI students are encouraged to seek residencies in the five-state region.

Since many doctors end up staying in the area where they do their residency, it is important to the goal of training doctors for rural and underserved communities, such as Montana and Idaho, for schools to encourage students to complete in-state residencies.

Four years ago, Idaho went through the uncertainty that Montana is going through now. That’s when the for-profit Idaho College of Osteopathic Medicine was founded, leading to worries that the school would hamper WWAMI students’ clinical training opportunities there.

Dr. Tracy Farnsworth, ICOM’s president, said the school created more than 50 clinical affiliations and hundreds of affiliations with private physicians to avoid conflicts.

Now, both Farnsworth and WWAMI’s Idaho director, Dr. Jeff Seegmiller, say their schools are united by the goal of boosting Idaho’s number of physicians per capita, the second-worst ratio in the nation.

“In our view, we need WWAMI, but we also needed Idaho College of Osteopathic Medicine. To become something other than last in the nation for physicians, you need more resources, more ability to generate physicians,” Farnsworth said.

ICOM has 486 students compared with WWAMI Idaho’s 160, and about three-quarters of the for-profit school’s students are from states outside of Idaho and the region.

Of the more than 800 physicians who have been trained by the Idaho WWAMI program, 51% of graduates return to practice in Idaho, according to Seegmiller.

ICOM’s first class will graduate in May 2022, so it is unknown how many of its students will return to the state.

Touro University College of Osteopathic Medicine, which is awaiting approval from accreditation agencies, plans to accept 125 students each year and to educate them with affiliates in Montana as well as sending some students out of state for their clerkships and rotations, according to Dr. Alan Kadish, president of the Touro College and University System.

He said Touro plans to give preference to Montana residents but does not have a quota on how many in-state vs. out-of-state students it will accept.

“With our [osteopathic] model and increased primary care residencies, we believe that we will encourage students to enter primary care and remain in the state,” Kadish said.

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Nevin, a Bozeman resident and now 55, said the process she went through about a decade ago was humiliating and she continually worried the judge would deny her request.

“I had to out myself just to get that court order, to basically every court staff member that I came in contact with,” she said. “Until it was all said and done, I was never sure if it was going to be OK.”

Montana health officials revised the rules governing birth certificate changes in 2017 so that other transgender people wouldn’t have to go through such an ordeal. Obtaining a judge’s order was an option, but people could simply fill out a form affirming that they had undergone a gender transition — and the rule did not explicitly define a transition as surgical. Gender-confirmation surgery is not necessary for people to undergo a gender transition.

But this spring, less than four years after those rules were implemented, the Republican-led Montana Legislature signed by Republican Gov. Greg Gianforte that once again requires a court order to change a birth certificate.

The state Department of Public Health and Human Services has proposed for the new law that say the court order must confirm “that the sex of an individual born in Montana has been changed by surgical procedure.”

A on the proposed rules for Thursday.

The new law and rules would affect dozens of people each year. The state health department fielded an average of 55 requests per year over the past three years to change the gender designation on their birth certificates, according to department spokesperson Jon Ebelt. In Montana, there are two designations for gender: male and female.

Fourteen require residents to provide proof of surgery to change the gender marker on their birth certificates, said Logan Casey, a senior policy researcher for the Movement Advancement Project, a research and advocacy organization.

“These kinds of laws are intrusive, overly burdensome and even dangerous for transgender people,” Casey said.

Anna Peterson, a psychotherapist from Missoula who primarily works with transgender people, said the requirement to not only get the surgery — which many transgender people do not get for various reasons — and then present proof of that surgery to a judge can prevent people from changing their birth certificates.

Having that identity-affirming document is very important, said Peterson, who is transgender. But going through such a public process is not only humiliating, as Nevin experienced, it can also expose them to perpetrators of hate crimes, as Casey noted.

“It can be really dangerous. Not to mention it can be psychologically harmful; it outs us and potentially puts us at risk,” Peterson said.

Supporters of the new law said the change is meant to ensure accurate statistical data. They also said the state health department did not have the authority to make such a drastic change in 2017 without legislative approval.

(R-Kila) sponsored Senate Bill 280, the legislation that became the new law. He said health department officials waited until after the legislature had convened in 2017 to begin the rule-making process to avoid input from the legislature on a major policy shift.

Glimm said his goal was to reverse that policy change and put the power of making such changes back in the hands of state lawmakers. The facts on a birth certificate are all important for statistical data and therefore a person must have a “very good reason” for changing them, he said.

Nevin, who now advocates for transgender rights and participated in on the wellness of rural transgender people, said she followed the bill through the legislative process and never heard a legitimate justification for changing the rules back.

“I would sure like to know what their reasoning was because everything I heard in the legislative hearings didn’t really amount to a good reason — other than that they were just upset that it happened,” Nevin said.

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Their provider, Dr. Lexi Tabor-Manaker, opened clinic in 2018. The model known as DPC, which can also stand for direct patient care, furnishes basic health care to patients for a set fee, often billed monthly like a subscription. The arrangement offers patients unlimited access to their doctors and allows them to communicate by phone or email. But the costs are all out-of-pocket.

“We have been pleased to be able to communicate with her instantly without going through an administrative gauntlet,” as he might with the Department of Veterans Affairs, Rana said.

Direct primary care practices have been emerging around the country, but they are often criticized for not offering the patient safeguards of traditional insurance. State legislators this year, however, sought to preserve the approach and passed two new laws that prohibit direct primary care practices or health care sharing ministries — religious or ethical groups whose members pool money to cover medical costs — from being regulated as insurance.

Such arrangements, according to supporters, afford greater flexibility and lower costs for health care compared with traditional health insurance. Without these laws, “a future commissioner of insurance may deem them to be insurance and require them to come under the health insurance regulatory scheme, thus destroying their value and defining characteristics,” said Sen. Tom McGillvray (R-Billings), sponsor of the bill on health care sharing ministries.

Lack of regulation comes with risks. Patients in direct primary care and health care sharing ministries mostly miss out on consumer protections mandated by the Affordable Care Act, such as coverage of preexisting conditions and prohibitions against charging more based on gender.

Some health care sharing ministries have developed into large nationwide organizations, such as and. Critics of that model say the to cap out-of-pocket costs or pay claims and can refuse coverage for certain treatments. They can also have annual and lifetime benefit caps.

In Montana, a pastor filed a lawsuit in 2007 for expenses for a member’s heart condition. A state judge ruled the group was selling insurance without registering in the state, effectively banning health care sharing ministries. That changed in 2017 when Matthew Rosendale, then insurance commissioner, declared and could operate in the state.

McGillvray’s bill cements Rosendale’s ruling into state law.

Eight direct primary care facilities operate in Montana with out-of-pocket fees that typically range from $70 to $120 per month for an adult, according to.

Supporters of direct primary care said the model lets doctors spend more time with patients. Physicians told lawmakers that when working with traditional insurance plans they might spend a significant chunk of their days on administrative tasks instead of patient care, according to Sen. Cary Smith (R-Billings), sponsor of the direct primary care bill.

That bill allows for any form of health care practice — therapists, dentists, physical therapists, etc. — to operate under the direct primary care model.

Direct primary care agreements don’t cover hospital visits, prescription drugs, surgery or specialized care, such as cancer treatment. Providers and supporters recommend people sign up for health insurance to cover those costs.

Another criticism, one leveled by traditional health insurers, is that the monthly fee often doesn’t save people money. Patients would have to go to the doctor several times a year to make the direct primary care monthly payments worthwhile, and people usually don’t make that many visits, said Richard Miltenberger, CEO of Mountain Health Co-Op, a nonprofit health insurance cooperative that sells health insurance in Montana, Idaho and Wyoming.

“So, it’s actually often, for many consumers, more cost-effective to just pay for the service [that isn’t covered by insurance] when you utilize it, as you utilize it, as opposed to paying a monthly membership fee,” Miltenberger said.

Rana, a retired Army veteran who lives in Woods Bay, doesn’t fully depend on direct primary care for his health care. He still uses the VA clinic for regular checkups. He also has Medicare and Tricare — a health program for military members and their families — for larger procedures he gets outside of the VA, such as when he had knee surgery in 2020.

But his first stop when he noticed something wrong with his knee was with Tabor-Manaker, who saw him quickly and referred him to a specialist. That makes the expense worth it, he said.

“I knew going in that this was all out-of-pocket for me, and I accepted that because the quality of service is far greater in its value to me than the hundred bucks a month,” Rana said.

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