Overview of Montana’s Big Sky Waiver
Montana’s Big Sky Waiver (BSW) is a Medicaid program for MT residents who are elderly or disabled and at risk of institutionalization (nursing home admission). Intended to prevent and delay unnecessary nursing home placements, long-term services and supports (LTSS) are available to assist persons in living independently in their homes or another community setting. Benefits may include adult day care, home and vehicle modifications, personal care services, homemaker services, skilled nursing, personal emergency response systems, and respite care. Transitional services to assist current nursing home residents in moving back to the community are also available.
Program participants can reside in their home, a loved one’s home, an adult foster care home, a community adult group home, or an assisted living residence.
While services offered under the Big Sky Waiver can be provided by licensed agency providers, program participants also have the option of self-directing their own care. This means they can hire, manage, and even fire, the caregiver of their choosing. This allows them to hire a friend or family member, including an adult child or a spouse, to provide them with care. A Financial Management Services Agency handles the financial aspects of employment responsibilities, such as tax withholding, background checks, and caregiver payments.
Montana’s Big Sky Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. The BSW is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. The number of participant enrollment slots are limited, and when these slots are full, a waitlist for program participation forms.
Benefits of Montana’s Big Sky Waiver
Follows is a list of home and community based services available via the BSW for adults and seniors. The exact benefits a program participant receives is based on an individualized service plan.
– Adult Day Health Care
– Adult Foster Care Services – i.e., supervision, light housecleaning, personal care assistance
– Assisted Living Services – i.e., supervision, homemaker services, personal care assistance
– Audiology Services
– Case Management
– Community Supports – participant directed option which allows program participants to hire the person of their choosing for services, such as personal care, household chores, meal preparation, and respite care
– Community Transition Services – covers security deposit, utility set-up fees, and essential home furnishings to assist persons in transitioning from a nursing home back into the community
– Consultive Clinical and Therapeutic Services
– Consumer Goods / Services – self-directed option that allows participant to purchase goods / services not otherwise available that increase their independence and safety at home
– Day Habilitation
– Dietetic Services
– Chore Services – i.e., heavy cleaning, yard work, minor home repairs
– Health and Wellness – i.e., weight loss, smoking cessation, art therapy
– Homemaker Services – i.e., preparation of meals, light housecleaning
– Home Meal Delivery
– Home Modifications – for safety and accessibility (i.e., wheelchair ramps, grab bars, widening of doorways)
– Non-Medical Transportation
– Senior Companion
– Supports for Persons Self-Directing their Care – financial management services, information / assistance
– Pain and Symptom Management
– Personal Assistance Services
– Prevocational Services
– Personal Emergency Response Systems
– Post Acute Rehabilitation Services
– Private Duty Nursing
– Residential Habilitation / Community Adult Group Homes – for individuals with severe disabilities
– Respite Care – in-home and out-of-home care to relieve a primary caregiver
– Specialized Medical Equipment / Supplies
– Supported Employment
– Therapies (Occupational, Physical, Respiratory, Speech)
– Supported Living – for persons with brain injuries / other severe disabilities
– Vehicle Modifications – for safety and accessibility
While program participants can reside in adult foster care homes, community adult group homes, and assisted living residences, Montana Big Sky will not pay for room and board in these residences.
Eligibility Requirements for Montana’s Big Sky Waiver
Applicants for the BSW must be Montana residents who are seniors (65+ years old) or between 0 and 64 and disabled. Disabled persons can continue to receive Waiver services as an aged individual upon turning 65. Additional eligibility criteria for the elderly as follows below.
Financial Criteria: Income, Assets & Home Ownership
The single applicant income limit is $914 / month. This figure is equivalent to 100% of the Federal Benefit Rate (FBR) for 2023. When both spouses of a married couple are applicants, each spouse is considered as an individual applicant and is permitted up to $914 / month. When only one spouse is an applicant, the individual income limit of $914 / month applies to the applicant spouse and the income of the non-applicant spouse is disregarded. However, in some cases, income can be allocated to the non-applicant spouse from the applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance (MMNA).
In Montana, there is a minimum income allowance, which is set at $2,465 / month (eff. 7/1/23 – 6/30/24). This allows the applicant spouse to transfer up to $2,465 / month to their non-applicant spouse in order to bring their monthly income up to this amount. The state also sets a maximum income allowance, which in 2023, is $3,716 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount they can receive is dependent on their shelter and utility costs. However, a Spousal Income Allowance can never push a non-applicant’s total monthly income over $3,716.
In 2023, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $2,000 per spouse. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can have $2,000 in assets, while the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment.
In 2023, the CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $148,620. If 50% of the couple’s assets falls under $29,724, the non-applicant spouse can keep 100% of the couple’s assets, up to this amount.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for eligibility purposes, Medicaid in MT considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has Intent to Return, and in 2023, their home equity interest is no greater than $688,000. Home equity is the current value of the home minus any outstanding mortgage. The applicant’s home equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child living in the home.
– The applicant has a disabled child of any age living in the home.
While the home is likely exempt while one is receiving Medicaid benefits, it may not be safe from Medicaid’s Estate Recovery Program. Learn more about the potential of Medicaid taking the home here.
Medical Criteria: Functional Need
An applicant must require a Nursing Facility Level of Care (NFLOC). For the Big Sky Waiver, a Level of Care (LOC) determination is completed by a registered nurse employed by Mountain Pacific Qualify Health (MPQH). Limitations in the ability to independently complete Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) are considered. These activities include bathing, mobility, dressing, eating, toileting, transferring, grooming, medication, shopping for essentials, cooking, housework, laundry, and money management. While persons with Alzheimer’s disease or a related dementia commonly need assistance with their ADLs and IADLs due to cognitive decline, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Learn more about long-term care Medicaid in Montana here.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for MT Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
Montana has a Medically Needy Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s Medically Needy income limit. The amount that must be “spent down” can be thought of as a deductible. Once one’s “deductible” has been met, the Big Sky Waiver will pay for care services and supports.
When persons have assets over the limit, trusts are an option. Irrevocable Funeral Trusts (IFTs) are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts (MAPTs), which must be implemented well in advance of the need for care, are trusts that protect assets from Medicaid and the Medicaid Estate Recovery Program. Another planning technique, although very complicated and requires professional assistance, is the Modern Half a Loaf. With this strategy, approximately half of one’s excess assets are gifted, and with the other half, an annuity is purchased. An annuity turns a lump sum of assets into a monthly income stream, with which one can pay for long-term care during the penalty period for gifting assets. There are additional planning strategies available when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Montana to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of the strategies violate Medicaid’s 60-month Look Back Rule, and therefore, should only be implemented with careful planning. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.
How to Apply for Montana’s Big Sky Waiver
Before You Apply
Prior to submitting an application for the BSW, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
Since Montana’s Big Sky Waiver is not an entitlement program, there may be a waitlist for program participation. This Waiver is approved for a maximum of approximately 2,580 beneficiaries per year. In the case of a waitlist, an applicant’s access to a participant slot is prioritized based on need. This means that a person who submitted an application at a later date than other applicants may be awarded a participant slot first if their needs are greater.
To be eligible for Montana’s Big Sky Waiver, one must be eligible for Montana Medicaid. Persons can apply online or via their local Office of Public Assistance. For application assistance or questions, persons can contact the Montana Public Assistance Helpline at 888-706-1535.
Applicants should also contact Mountain Pacific Quality Health at 800-219-7035 to initiate the Level of Care determination (functional needs assessment).
Limited information about the BSW can be found here.
Montana’s Department of Public Health & Human Services’ (DPHHS) Division of Senior & Long Term Care (SLTC) administers the Big Sky Waiver. The Office of Public Assistance (OPA) determines financial eligibility and Mountain Pacific Qualify Health (MPQH) determines functional eligibility.
Approval Process & Timing
The Montana Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as a waitlist may exist, approved applicants may spend many months waiting to receive benefits.
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization, and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a Nursing Home Level of Care and are at risk of institutionalization, such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.