Montana is set to begin enforcing new Medicaid work requirements Oct. 1, months ahead of the federal deadline, as some enrollees and lawmakers say unclear notices and limited support could leave eligible people at risk of losing health coverage. Nearly 71,000 Montanans are subject to the rules. They must document at least 80 hours a month of work, volunteering or study, or show that they qualify for an exemption. Exemptions include being medically frail or serving as the primary caretaker for a family member. The state began a soft launch in July and gave enrollees until Oct. 1 to comply. Bethany Zulick, a Missoula resident studying to become a teacher, said a letter from the Montana Department of Public Health and Human Services left her unsure when she had to provide proof. It said documentation could be due at her next renewal, expected next spring, but also directed her to submit paperwork within 30 days of the letter’s June 26 date. Zulick later married and no longer qualified for Medicaid, but when the letter arrived she feared she could lose coverage if she misunderstood the deadline. Students such as Zulick also cannot yet rely on an automated system to verify enrollment at public universities; state officials expect that system to be ready next year. State Rep. SJ Howell, a Democrat, said constituents have called with questions about the notices. At a September legislative hearing, Howell described the letters as confusing and said it was difficult for residents to find help understanding the rules. State health officials told lawmakers they had revised the notices to make them clearer. The department says it is prepared for the rollout and expects to process about 5,000 enrollees a month. But officials told lawmakers that only about 20 of 59 planned positions were filled, after staff turnover. The state health department said it would monitor implementation and work to keep eligible residents covered while they meet the requirements. Help outside state government has also shrunk. Cover Montana, a nonprofit that assists residents with health coverage paperwork, went from 18 staff members to two part-time employees answering a phone line after losing federal funding. Federal data cited in the report shows Montana callers face longer waits than the national average on the state helpline, and many hang up before reaching an employee. Aaron Wernham, head of the Montana Healthcare Foundation, said the state’s rushed rollout and limited public information could produce confusion. He pointed to the 2023 Medicaid eligibility review, when roughly 87,000 Montanans lost coverage for procedural reasons, according to state data from that period. Some people who were financially eligible were dropped because of paperwork problems. Montana is one of three states, along with Nebraska and Arkansas, that began implementing the requirements before the Jan. 1 federal deadline. The state Legislature backed adding work rules in 2019, but Montana lacked federal approval to proceed until recently. Republican Senate President Matt Regier said the requirements promote accountability and that the Oct. 1 deadline gave the state time to address early problems. Critics say the rollout could foreshadow challenges elsewhere as states build systems to track compliance. Akeiisa Coleman, a Medicaid analyst with the Commonwealth Fund, said states may have to review cases manually if automated systems are not ready, potentially creating backlogs and disrupting coverage. Montana lawmakers have asked health department leaders to extend the compliance deadline, but department leadership has said it has no plans to do so. For Heather Reel, who relies on Medicaid for mental health care while working at a fast-food restaurant and caring for her teenage son, the paperwork itself is a concern: she fears she may not have time to report her hours.