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Health Care Coverage:
Are You Eligible?

Medicaid and Affordable Care Act programs are governed under broad federal guidelines, but every state is allowed to set its own eligibility standards, decide which services to cover and for how long, and set the rate of payment for services. These policies vary considerably from state to state. A person who is eligible for Medicaid in another state is not necessarily eligible in Montana. Also, the services provided by Montana Medicaid may differ considerably from those provided in other states.

To apply for Medicaid or coverage under the Affordable Care Act, or to find out if you are eligible, call or visit your local Office of Public Assistance, or go to www.HealthCare.gov

Basic Eligibility Requirements

To be eligible for Montana Medicaid or Affordable Care Act coverage, you must meet financial requirements that take into account your income and resources. You must be a Montana resident, and you must have proof of U.S. citizenship or alien status and identity. You also must fall into one of these groups:

  • Parents or other related adults with dependent children under age 19
  • Children
  • Former foster care children age 18 up to 26
  • Pregnant women
  • Women diagnosed with breast or cervical cancer or pre-cancer
  • People aged 65 or older
  • People who are blind or disabled (based on Social Security criteria)

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Full vs. Basic Medicaid

Medicaid recipients get either full or basic Medicaid coverage depending on which eligibility group they fall into. You may be eligible for full coverage if you are:

  • Under age 21
  • Blind or disabled
  • Age 65 or older
  • Pregnant

That means you can get all services that Medicaid covers that are medically necessary.

If you don’t fall into one of the above groups, you may be eligible for basic Medicaid coverage. This covers all Montana Medicaid services except for dental care, audiology services, vision exams, eyeglasses, durable medical equipment, and personal-care services in your home. In some cases, such as emergency situations, people getting basic coverage may be able to get some of the excluded services.

Montana Medicaid is divided into two main categories: family-related Medicaid and Medicaid for people who are aged, blind, or disabled.

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Family-Related Medicaid Programs

In Montana, there are several Medicaid programs that provide coverage for families, children, pregnant women, and women diagnosed with breast or cervical cancer or pre-cancer.

To be eligible for these programs, you must meet the basic eligibility requirements as well as some other specific financial and non-financial requirements.

Program descriptions:
Following are brief descriptions of the different Medicaid programs for families and children:

  • Medically Needy. This program is for individuals and families whose income exceeds program standards but who have a significant medical need. Resource limit for medically needy individuals depends on household size. The individual or family pays the difference between their countable income and the Medically Needy Income Limit (MNIL) toward medical expenses each month. Medicaid pays the balance. The difference between countable income and the MNIL is called a “spend-down” or “incurment.” The incurment can be met by making cash payments to the State of Montana, incurring medical bills or obligations, or a combination of the two. If a family Medicaid case is considered medically needy, only the children involved can get Medicaid coverage.
  • Child – Newborn. This program provides coverage for children from birth through age 1 when the mother was getting Medicaid at the time of the child's birth. Coverage continues through the month of the child's first birthday as long as child continues to live in Montana. There is no income or resource limit.
  • Child – Medically Needy. This program provides coverage for children through the month of their 19th birthday when their countable income exceeds the HMK Plus income limits. This program has a $3,000 resource limit and is only for children who are medically needy. They cannot be living with a parent or specified relative. Children who are living with their parent or other specified relative can receive Medicaid coverage under the Family-Medically Needy program, if otherwise eligible.
  • Family – Transitional. Transitional Medicaid covers families whose Family Medicaid case becomes medically needy due to a qualifying event. Such families are eligible for up to 12 months of transitional coverage. A qualifying event is new or increased earned income. Coverage for the period is guaranteed as long as the family stays in Montana and remains employed. There is no income or resource limit.
  • Qualified Pregnant Woman. This medically needy program provides coverage for pregnant women of any age whose countable income exceeds the allowable limits for the Pregnancy program. Coverage continues for as long as the woman meets the monthly incurment amount, her countable resources do not exceed $3,000, and she remains a Montana resident.
  • Pregnancy – Extended. This program provides full Medicaid coverage through the last day of the month of the 60th day after the pregnancy ends. This program is available to women who were getting Medicaid at the time their pregnancy ended. Coverage may be for both mother and child. There is no resource or income limit.
  • Breast and Cervical Cancer Treatment. This is a program for women who are diagnosed with breast or cervical cancer or a precancerous condition of the breast or cervix. To be eligible, a woman must be under 65 years old, not have insurance that is considered to be “creditable coverage,” meet citizenship or qualified alien requirements, be a Montana resident, and have been screened through the Montana Breast and Cervical Health Program. Eligibility for this program begins the month of diagnosis (if the woman applies within three months of her diagnosis) and ends when the woman finishes treatment, gets creditable coverage, or turns 65 years of age. She must also remain a Montana resident and cooperate with the Third Party Liability Program of the Quality Assurance Division.

Non-financial eligibility requirements:

  • Live with a specified relative. To be eligible for some Family-Related Medicaid programs, children under age 19 must live with an adult family member who is within the fifth degree of kinship. Adults must have a minor relative child living with them in order to be eligible, unless the adult is 65 or older, blind, disabled, or pregnant. Other Medicaid programs allow children to be eligible while living independently or with other individuals.
  • Cooperate with the Child Support Enforcement Division. To get Medicaid coverage under either the Family, Family-Extended, or Qualified Pregnant Woman programs, adults must cooperate with the Montana Child Support Enforcement Division to provide medical support for their children if one or more of the children has an absent parent.
  • Cooperate with the Third Party Liability Program. Adults must cooperate with the Third Party Liability (TPL) Program of the Quality Assurance Division. This includes providing health insurance information, cooperating with the Health Insurance Premium Payment System, completing trauma questionnaires (if they have certain injuries that may have occurred as a result of an accident), and maintaining cost-effective group health insurance.
  • Fit within age parameters. Certain Medicaid programs require applicants to be within specific age parameters, such as under age 19.
  • Provide a valid Social Security number.
  • Provide proof of U.S. citizenship or alien status and proof of identity (original documents must be provided).
  • Cooperate with Program Compliance Bureau. Program Compliance Bureau staff at the Department of Public Health and Safety randomly review Medicaid cases to make sure they are appropriate. If your case is selected for review, you must cooperate by providing requested information.

Financial eligibility requirements:

  • Resources. Some Medicaid programs have a limit on the value of resources a household can own and still qualify for Medicaid. For programs with a resource limit, your total countable resources must be at or below $3,000 per household regardless of household size. Many resources are excluded. For example, you can exclude one vehicle with the highest equity value and all income-producing vehicles. The equity value of any other vehicles is counted toward the $3,000 limit. Your residence is also excluded.
  • Income. Income limits vary depending what coverage is requested.

Income Limits

Child – Newborn  - No income limit

Family – Transitional - No Limit

Child – Medically Needy


Household Size

Medically Needy Income Standard

1 $525
2 $525
3 $658
4 $792
5 $925
6 $1058
7 $1192
8 $1317

Qualified Pregnant Woman


Household Size

Medically Needy Income Standard

1 $525
2 $525
3 $658
4 $792
5 $925
6 $1058
7 $1192
8 $1317

Breast & Cervical Cancer Treatment        200% of Federal Poverty Level


Household Size

Countable Income Standard

1 $1945
2 $2622
3 $3298
4 $3975
5 $4652
6 $5328
7 $6005
8 $6682

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Affordable Care Act Programs

Affordable Care Act (ACA) related program eligibility is based on income tax filing status and their tax dependents. There are no resource limits for the following programs. To determine eligibility for ACA programs, a standard 5% disregard is applied.

To be eligible for these programs, you must meet the basic eligibility requirements as well as some other specific financial and non-financial requirements.

Program descriptions:
Following are brief descriptions of the different ACA programs for families and children:

  • ACA HMK Plus. This program is for children through the month of their 19th birthday. Children are not required to live with a specified relative to be eligible under this program.
  • ACA HMK. This program, formerly known as the Children’s Health Insurance Program (CHIP), is a free or low-cost health coverage plan for eligible children through the month of their 19th birthday. Children are not required to live with a specified relative to be eligible under this program. More on ACA HMK.
  • ACA Parent/Caretaker Relative. This program provides medical coverage for a parent or caretaker relative who has a related dependent child under age 19 living with them in the home.  The individuals who live together must be related by marriage and/or parentage. Child support cooperation is required.
  • ACA Pregnancy. This program covers pregnant women of any age whose income is within the allowable limits. If countable income is within the required limits during the month in which the woman applies, she is guaranteed continuous coverage throughout her pregnancy. She must also remain a Montana resident and cooperate with the Third Party Liability Program of the Quality Assurance Division.

If a pregnant woman's countable income exceeds 157 percent of the federal poverty level at the time she applies, she may be eligible for medically needy coverage under the Qualified Pregnant Woman program. Women eligible for and receiving either Pregnancy or Qualified Pregnant Woman Medicaid at the time of birth are also eligible for Pregnancy-Extended coverage.

  • ACA Former Foster Care. This program is for individuals who were in foster care and receiving Medicaid the month they turned 18. These individuals may apply for the Former Foster Care program and be determined eligible through the month of their 26th birthday. There is no income or resource limit for this program.

Non-financial eligibility requirements:

  • Live with a specified relative. To be eligible for some ACA-related programs, children must live with an adult family member who is within the fifth degree of kinship. Other programs allow children to be eligible while living independently or with other individuals.
  • Cooperate with the Child Support Enforcement Division. To get coverage under either the ACA Parent/Caretaker Relative program, adults must cooperate with the Montana Child Support Enforcement Division to provide medical support for their children if one or more of the children have an absent parent.
  • Cooperate with the Third Party Liability Program. Adults must cooperate with the Third Party Liability (TPL) Program of the Quality Assurance Division. This includes providing health insurance information, cooperating with the Health Insurance Premium Payment System, completing trauma questionnaires (if they have certain injuries that may have occurred as a result of an accident), and maintaining cost-effective group health insurance.
  • Fit within age parameters. Certain ACA programs require applicants to be within specific age parameters, such as under age 19.
  • Provide a valid Social Security number.
  • Provide proof of U.S. citizenship or alien status and proof of identity.
  • Cooperate with Program Compliance Bureau. Program Compliance Bureau staff at the Department of Public Health and Safety randomly review Medicaid cases to make sure they are appropriate. If your case is selected for review, you must cooperate by providing requested information.

Financial eligibility requirements:

  • ACA Income Limits - Income limits vary depending what coverage is requested.

ACA Former Foster Care (age 18-25) - No Income Limit

ACA Parent/Caretaker Relative - 48% of Federal Poverty Level


Household Size

Countable Income Standard

1 $453
2 $607
3 $761
4 $916
5 $1,070
6 $1,225
7 $1,380
8 $1,533

ACA Pregnancy - 157% FPL


Household Size

Countable Income Standard

2 $2,058
3 $2,589
4 $3,120
5 $3,652
6 $4,183
7 $4,714
8 $5,245

ACA HMK Plus - 143% FPL


Household Size
Countable Monthly Income Standard
2 $1,874
3 $2,358
4 $2,842
5  $3,326
6 $3,810
7 $4,294
8 $4,777

ACA HMK (under age 19) - 143% of Federal Poverty Level (FPL)

2014 HMK Income Chart
Monthly Gross Income
Effective January 1, 2014
Household Size (Children and Adults) Monthly Household Income
Family of 2 $3,431
Family of 3 $4,304
Family of 4 $5,187
Family of 5 $6,070
Family of 6 $6,953
Family of 7 $7,837
Family of 8 $8,720

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Medicaid for the Aged, Blind & Disabled

Several Medicaid programs provide coverage for Montanans who are 65 or older or who are under age 65 but meet the Social Security Administration's definition of blind or disabled.

Aged, blind, and disabled individuals who get Medicare and who meet certain income limits also may qualify for a Medicare Savings Program. This pays the Medicare Part B premium and, in the case of those with extremely low incomes, Medicare Part A premiums (when applicable) and Medicare deductibles and co-insurance amounts.

In addition to the basic Medicaid requirements, participants in the Aged, Blind & Disabled programs must meet certain financial and non-financial requirements.
Non-financial eligibility requirements:

  • Cooperate with Third Party Liability. Adults must cooperate with the Montana Third Party Liability (TPL) Program of the Quality Assurance Division. This includes providing health insurance information, cooperating with the Health Insurance Premium Payment System, completing trauma questionnaires (if they have certain injuries that may have occurred as a result of an accident), and maintaining cost-effective group health insurance.
  • Meet age or condition criteria. The applicant must be 65 or older or be blind or disabled as defined by the Social Security Act.
  • Provide valid Social Security number.
  • Cooperate with Program Compliance. Program Compliance Bureau staff at the Department of Public Health and Safety randomly review Medicaid cases to make sure they are appropriate. If your case is selected for review, you must cooperate by providing requested information.

Financial eligibility requirements:

  • Resources. For regular Medicaid, total countable resources must be at or below $2,000 for an individual or $3,000 for a married couple. For Medicare Savings Programs, the limit is $7,080 for an individual or $10,620 for a married couple. Many resources are excluded. For example, one vehicle with the highest equity value is excluded. The value of income-producing vehicles may also be excluded. The equity value of all other vehicles is counted toward the resource limit. The applicant's primary place of residence is excluded. Pre-paid funeral agreements may also be excluded.

A resource assessment is completed when a married person applies for institutional coverage. A resource assessment combines the value of all assets owned by both spouses and allows a portion of that combined value to be retained by the spouse not needing nursing home care. The amount retained varies based on the combined value and minimum and maximum allowances set each year (2014 minimum is $23,448 and maximum is $117,240).

When a person or his or her spouse who is applying for nursing home or waiver Medicaid coverage has transferred assets without getting adequate compensation for those assets, the applicant may be penalized and will be ineligible to receive Medicaid benefits for the nursing home or waiver care. Any assets transferred within 60 months of the date the person is both living in a nursing home (or getting waiver services) and applies for Medicaid are evaluated for possible asset transfer penalties.

  • Income. There is no true income limit for most Medicaid programs for the aged, blind, or disabled. However, the applicant's income determines whether the applicant must meet a deductible (also known as an incurment or spend-down amount) before getting Medicaid coverage.

Program descriptions:

  • Categorically Needy Medicaid. To be eligible for regular Medicaid with no deductible, an aged, blind, or disabled applicant's countable monthly income must be equal to or less than
    • $721 for a single person
    • $1,082 for a married couple (sometimes even if only one is aged, blind, or disabled)
  • Medically Needy Medicaid: If an aged, blind, or disabled applicant's countable monthly income is greater than the amounts listed above, then the household (either an individual or a couple) will have a monthly deductible equal to the amount of countable income of the household that exceeds $625 per month. The deductible, called an incurment or spend-down, can be met by making cash payments to the State of Montana, incurring medical bills or obligations, or a combination of the two.
  • Medicaid for Residents of Nursing Facilities. An aged, blind, or disabled individual living in a nursing facility must have income that is less than the monthly Medicaid payment rate for the facility in which she or he lives. If Medicaid-eligible, a nursing home resident will contribute most of his or her income toward the cost of his or her care in the facility.

However, a nursing home resident is allowed to keep up to $50 a month for personal needs as well as whatever amount is needed to pay health insurance premiums, legally obligated child support and alimony expenses, and, in some cases, an allowance for a spouse living in the community or a home maintenance allowance (for a limited period).

An aged, blind, or disabled person who is married but living in a nursing facility will have his or her income eligibility determined based solely on his or her individual income. He or she may also be allowed to pass some or all of his or her income to the spouse remaining in the community, depending on that spouse's own income.

  • Medicare Savings Programs. The Medicare Savings Programs are limited Medicaid benefits that vary by program.
  • A Qualified Medicare Beneficiary pays Medicare Part A (when applicable) and Part B premiums, Medicare deductibles, and Medicare co-payments. Income limits are:
    • $958 for a single individual
    • $1,293 for a married couple (even if only one is a Medicare beneficiary)
  • A Special Low Income Medicare Beneficiary pays only Medicare Part B premiums. The monthly income ranges are:
    • $958.01 - $1,149.00 for a single individual
    • $1,293.01 - $1,551.00 for a married couple (even if only one is a Medicare beneficiary)
  • A Qualifying Individual pays only Medicare Part B premiums. The monthly income ranges are:
    • $1,149.01 - $1,293.00 for a single individual
    • $1,551.01 - $1,745.00 for a married couple (even if only one is a Medicare beneficiary)

Receipt of any Medicaid coverage automatically entitles a Medicare beneficiary to Social Security Extra Help for payment of basic Medicare Part D Prescription Drug Plan premiums. It also limits prescription drug co-payments to $1 to $5 per prescription.

Medicaid does not pay for prescription drugs for those who are getting Medicare benefits or who are eligible for Medicare benefits but refuse to apply for them.

Health Coverage Assistance under the Affordable Care Act

The Affordable Care Act (ACA) requires most Americans to have health insurance in 2014. Visit HealthCare.gov  to explore health insurance options and select the best choice for yourself and your family.

  • Open enrollment is October 1, 2013, to March 31, 2014
  • Coverage begins as soon as January 1, 2014
  • If you already have Montana Medicaid or HMK coverage, no action is needed.   Your existing coverage will continue, and when your case is up for renewal, your case worker will inform you of any changes.
  • To apply for Healthcare Coverage Assistance under the Affordable Care Act, go to www.healthcare.gov or call 1-800-318-2596.

More information on other Montana Public Assistance Programs

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Page last updated: 04/01/2014