Medicaid is health care coverage for some low income Montanans. Medicaid is run by DPHHS (the Montana Department of Public Health and Human Services). The State of Montana pays about one-third of the cost of Medicaid and the federal government pays the rest.
Medicaid does not pay money to you. Instead, it sends payments directly to your health care providers.
- If Medicaid pays for health care:
- Services must be medically necessary
- Services must be provided by a health care provider who is a Montana Medicaid provider
- Services must be Medicaid-covered services
(See pages 20-37 of the Medicaid Member Guide)
As of October 1, 2009 Montana Medicaid for children, ages 0-19,is called Healthy Montana Kids Plus. The services kids received from children’s Medicaid are the same services now available from Healthy Montana Kids Plus. Adults with Medicaid will still get services from Medicaid. To learn more about or to sign up for Healthy Montana Kids Plus go to: http://hmk.mt.gov/familyresources.shtml
Go to your local County Office of Public Assistance to apply for Medicaid. Optionally, you may mail in your Medicaid application and have your Medicaid interview conducted by telephone.”
Services covered depend on whether member receives full or basic benefits.
Full benefits means that you are eligible for all services that Medicaid covers if
medically necessary. The following individuals may be eligible for full benefits:
- pregnant women,
- children age 20 and under, and
- adults who are blind, age 65 or older or disabled and anyone receiving Supplemental Security Income (SSI).
Basic benefits means that some services are not paid for by Medicaid, except in the case of an emergency, or where a job requires the services (“essential for employment” - check with your eligibility case manager). This includes adults receiving Medicaid over age 20 who are:
- not pregnant,
- not blind,
- under age 65, and
- not disabled or receiving SSI
Some covered services may (depending on Full or Basic benefit status) include:
ambulance, anesthesiology, blood lead testing, dialysis, durable medical equipment, prescription drugs, emergency room (emergencies only), eyeglasses, family planning, hearing specialists, home health services, hospital outpatients, nursing home care, immunizations, lab work, mental health services, nutrition services, occupational therapy, outpatient surgery, physical therapy, podiatry, physician services, pregnancy and childbirth care, social worker services, speech therapy, tobacco cessation, transportation to appointments, well-child checkups, x-rays.
There are limits on many of these services. See pages 20 - 37 of the Medicaid Member Guide for more information.
A resource is real or personal property that has economic value. Resources can include, but are not limited to cash savings, investments, house, land, vehicles, etc. The filing unit’s resources are evaluated for ownership, accessibility, and equity value. All resources are countable unless specifically excluded by regulation.
Many resources are excluded including your place of residence. Vehicles may be excluded including one vehicle with the highest equity value and income-producing vehicles.
- Proof of age, like a birth certificate or Medicare card.
- Proof of citizenship or alien status.
- Identification, such as a driver’s license.
- Recent paycheck stubs (if you are working).
- Proof of income from sources like Social Security, Supplemental Security Income (SSI), Veteran’s Benefits (VA), retirement.
- Any bank statements and insurance policies that you may have.
- Proof of where you live, like a rent receipt or landlord statement.
- Insurance benefit card or the policy (if you have any other health insurance).
- Medicare Benefit card (if eligible for Medicare).
Yes, under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), a tribal enrollment card (ID) or certificate of degree of Indian blood can be used to document both U.S. citizenship and identity when applying for Medicaid.
No, both are now excluded. The American Recovery and Reinvestment Act of 2009 (ARRA) requires states to disregard property that is held in trust, or under supervision of the Secretary of the Interior, when determining Medicaid eligibility. Payments from trust lands, including money IIM Accounts, are now excluded.
No, the Health Insurance Premium Payment program may pay for Medicaid members to have another type of health insurance besides Medicaid if it is cost effective for the program. Here are some examples of ways you may be eligible for this program:
- you have insurance either through your job or an individual health policy
- your job offers insurance, but you haven't signed up because it costs too much
- you have a new job, and your insurance won’t start for awhile
- you had insurance through your job, but you are no longer working but may qualify for COBRA.
If you have private insurance, or if private insurance is available to you, please contact your eligibility case manager. Before Medicaid pays your insurance premium, we review health problems in your family and check the cost and coverage of your insurance plan. If your insurance is found to be "cost effective," Medicaid will pay the premium. You will then be covered by both private insurance and Medicaid. You will get a Medicaid card.
For more information about the Premium Payment Program, call 1-800-694-3084.
If you have other health insurance in addition to Medicaid, or if someone else pays for your medical bills, Medicaid is usually billed last. However, Medicaid would be billed before Indian Health Services and Crime Victim’s Compensation. Examples of other health insurance include:
- private health insurance companies
- health maintenance organizations (HMOs); or
- anyone else who should pay for your medical costs.
Yes, call your local Office of Public Assistance and ask how this can be done.
Medicaid member rights
A person who is eligible for Medicaid has the right to be treated fairly and with courtesy and respect.
- You have the right to have your privacy protected and to be treated with dignity by health care providers and their staff.
- You have the right to get medical care no matter what your race, color, nationality, sex, religion, age, creed, physical or mental disability, marital status, or political belief.
- You have the right to know if the medical services you need are paid for by Medicaid.
- You have the right to get information on all available treatment options.
- You have the right to participate in decisions about your medical care. You have the right to refuse treatment.
- You have the right to discuss possible results with your provider before accepting or refusing treatment.
- You have the right to use the services of an interpreter if necessary, at no cost to you.
- You have the right to make a complaint about Medicaid and to receive an answer.
- You have the right to choose your medical provider, unless you have Team Care.
Doing your part - Your responsibilities as a Medicaid member
You and your health care provider are a team. Your job is to help your health care provider give you the best health care. Here’s what you can do:
- Treat your doctor and other health care providers with respect, just as you like to be treated.
- Call the Nurse First Advice Line—first. Nurses are there every day, 24 hours a day to help you decide if you should see your provider, go to the emergency room, or take care of the problem at home. Call 1-800-330-7847.
- Don’t use an ambulance or go to an emergency room if you do not have an emergency. An emergency room visit costs at least $150, but a visit to your provider costs much less.
- Make an appointment with your PCP or get your PCP’s okay to make an appointment with another provider. Ask if the other provider is a Medicaid provider.
- Get to your appointments on time. Be sure to call ahead of time if you can’t keep the appointment or if you will be late.
- Help your provider get your last medical records.
- Tell your provider about signs of trouble, such as pain, allergies, or changes you’ve noticed.
- Ask questions: Make a list of questions before your appointment. Ask about risks, choices, and costs before getting treatments or prescriptions.
- Go to the same pharmacy to get all your prescriptions. The pharmacist will tell you if a drug combination will give you problems or if a drug has side effects. The pharmacist can also answer questions about your prescriptions.
- Get complete directions about medications, treatments, or tests. Write down the directions or ask your provider to write them down.
- Take time to decide about having a treatment. Think about your choices and discuss them with your provider. For some procedures, your provider will need an okay from Medicaid before the treatment is done.
- Don’t sign anything you don’t understand. Ask questions until you do understand.
- Pay your cost shares.
- Pay your provider any money you get from other payers for medical services, for example, an insurance company.
- Use Medicaid wisely—only when you are sick or for regular checkups to help prevent sickness.
- If you sue or seek claim for damages or compensation against another person or an insurance company for personal injury, illness, or disability for which Medicaid has paid or may pay for medical care, you must tell Medicaid the names and addresses of the person or company responsible. Call Tort Recovery at 1-800-694-3084.
- If you think someone with Medicaid is using Medicaid services unwisely or improperly, please call the Medicaid Help Line at 1-800-362-8312, or write to:
DPHHS Member Health Management Bureau
PO Box 202951
Helena MT 59620
Denial of Medicaid eligibility
If you have been denied Medicaid, you can contact your County Office of Public
Assistance to find out why. They can also tell you how to appeal.
Enrolled member Complaints
How to make a complaint:
If you want to make a complaint, call the Medicaid Help Line at 1-800-362-8312, Monday through Friday, 8 a.m. to 6 p.m. The call is free and confidential. Say that you would like to make a complaint.
What is a grievance?
A grievance is a written complaint. You can write about your complaint and send it to the Medicaid Help Line. Send your grievance to:
Passport To Health
PO Box 254
Helena, MT 59624
You can always request a fair hearing with the DPHHS Office of Fair Hearings if you disagree with a decision on eligibility, payment of your bill, or any other adverse action taken against you. A fair hearing is a formal legal process. To requests a hearing, you may call the Office of Fair Hearings at 406-444-2470 or write to:
DPHHS Office of Fair hearings
PO Box 202953
Helena, MT 59620-2953
It will often help to talk to your provider about your complaint. If that does not help, call the Medicaid Help Line at 1-800-362-8312.
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, a home maintenance allowance (for a limited period)or an allowance for a spouse living in the community.
Your coverage will be the same as in-state coverage. Out-of-state nursing home placements require pre-approval from Medicaid. Services must be short-term or not available in Montana and ordered by your provider. The facility must be willing to enroll as a Montana Medicaid provider or be certified by Montana Medicaid.
Some people who get Medicaid have to pay Medicaid back for services that were originally paid by Medicaid. If you go into a nursing home and own real property, Medicaid may place a lien on the real property. Real property is land and/or any building(s) on the land. When the real property is sold, money from the sale is used to repay Medicaid.
If you have a spouse or certain legal dependents or siblings living in the home, or if the real property is Indian trust property, a lien will not be placed on the property.
Medicaid will file a claim against the estate of a deceased member who received any benefits after age 54, or who resided in a nursing home or received Home and Community Based Services unless there is a surviving spouse or legal dependent. For more information about estate recovery and liens against property, call 1-800-694-3084.
Most Medicaid members are on the Passport to Health Managed Care Program. If you’re on Passport, you are required to choose a primary care provider – your Passport provider. Once you choose, you will get a letter in the mail with the name of your Passport provider and their after-hours phone number.
For most services, you must see your Passport provider or get their authorization before going to another provider or to the hospital for a non-emergency. If you don’t get your Passport provider’s okay or authorization, Medicaid may not pay and you may have to pay the bill.
For more information please visit Passport to Health.
In the Passport to Health Managed Care Program, you get exactly the same Medicaid benefits that you would get in regular Medicaid.
See pages 16-20 of the Medicaid Member Guide for more information.
Nurse First is a service for enrolled Medicaid members. It can be very helpful to call Nurse First before going to your health care provider or the emergency room – the Nurse First advice line provides health care services when you are sick, hurt, or have health care questions. Registered nurses ask about your symptoms, and can provide friendly, professional advice.
For more information please visit Nurse First.
Team Care is part of the Passport to Health Program for Medicaid members. Team Care is only for members who are misusing Medicaid services. If you have been enrolled in Team Care, you will receive a notice in the mail.
The Team Care Program helps you decide how, when, and where you should seek Medicaid services. You will continue to get the care needed, and a team to help you get the right care at the right place and the right time.
For more information please visit Team Care.
The Medicaid Health Improvement Program provides care management services for Medicaid and Healthy Montana Kids Plus patients with chronic illnesses or at risk of developing serious health conditions.
For more information please visit the Health Improvement Program.