- Basic Eligibility Requirements
- Full vs. Basic Medicaid
- Family-Related Medicaid
- Medicaid for the Aged, Blind & Disabled
Medicaid is 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. Medicaid 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 to find out if you are eligible, call or visit your local Office of Public Assistance.
To be eligible for Montana Medicaid, 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
- 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)
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
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.
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.
Non-financial eligibility requirements:
- Live with a specified relative. To be eligible for some Family-Related Medicaid programs, children 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. Staff of the Program Compliance Bureau 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. Most Medicaid programs have a limit on the value of resources a family can own and still qualify for Medicaid. For programs with a resource limt, your total countable resources must be at or below $3,000 per household regardless of family 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. The Family-Extended, Family-Transitional, Pregnancy-Extended, Breast and Cervical Cancer Treatment and Healthy Montana Kids Plus (HMK Plus) programs do not have resource limits.
- Income. Income limits vary depending what coverage is requested.
Child – Newborn No income limit HMK Plus (under age 19) 133% of Federal Poverty Level (FPL) Child – Medically Needy 33% FPL Family 33% FPL Family – Transitional No income limit Pregnancy 150% FPL Qualified Pregnant Woman 33% FPL Breast & Cervical Cancer Treatment 200% FPL
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. 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.
- 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.
- 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 is only for children who are medically needy. They cannot be living with a parent or specified relative. Children who are living with thier parent or other specified relative can recieve Medicaid coverage under the Family-Medically Needy program, if otherwise eligible.
- Family. This program provides medical coverage for children through the month of their 19th birthday if they are living with a specified relative. It also may cover the children's parents or specified relatives if the children are not considered medically needy. Child support cooperation is required. If the case is medically needy, only the children may be covered. The resource limit for this program is $3,000.
- 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.
- Family – Extended. Extended Medicaid covers families whose Family Medicaid case becomes medically needy due to a qualifying event. Such families are eligible for up to four months of Family-Extended coverage. A qualifying event is new or increased child support. There is no income or resource limit for this program.
- Pregnancy. This program covers pregnant women of any age whose income and resources are 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 as long as her countable resources do not exceed $3,000. She must also remain a Montana resident and cooperate with the Third Party Liability Program of the Quality Assurance Division. The resource limit for this program is $3,000.
If a pregnant woman's countable income exceeds 150 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. When the pregnant woman is a minor (under age 19) and lives with her parents, her parents' income and resources are considered when determining whether she is eligible for this coverage. Women eligible for and receiving either Pregnancy or Qualified Pregnant Woman Medicaid at the time of birth are also eligible for Pregnancy-Extended coverage.
- 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. Cooperation with the Child Support Enforcement Division is required.
- 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.
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. Staff of the Program Compliance Bureau 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 $6,940 for an individual or $10,410 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 (2012 minimum is $22,728 and maximum is $113,640).
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.
- 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
$698 for a single person
$1,048 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:
$931 for a single individual
$1,261 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:
$931.01 - $1,117.00 for a single individual
$1,261.01 - $1,513.00 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:
$1,117.01 - $1,257.00 for a single individual
$1,513.01 - $1,703.00 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.