Montana and the ACA’s Medicaid expansion

47,000 enrolled in expanded Medicaid in first 7 months

Where in your state to call or visit for Medicaid.How to apply

Online at or at, or by phone at 1-800-318-2596.  You can print a paper application and mail it to your local Office of Public Assistance, or enroll in person at an Office of Public Assistance.

Who is eligible in your state to get Medicaid?Who is eligible

Children are eligible for Medicaid with household income up to 143% of the federal poverty level (FPL), and CHIP with household income up to 261% of FPL. Pregnant women are eligible for Medicaid with household income up to 157% of FPL. Other adults are eligible for Medicaid with household income up to 138% of FPL (enrollment commenced November 2, 2015, for coverage effective January 1, 2016).

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  • September 29, 2016

Expanded Medicaid became effective January 2016

On November 2, 2015, CMS approved Montana’s Medicaid expansion waiver under the Affordable Care Act (ACA). Enrollment became available immediately, for coverage effective January 1, 2016. Under the expanded guidelines, Medicaid is available for all adults with incomes up to 138% of poverty (Medicaid and CHIP rules for children and pregnant women are higher, and remain unchanged by the waiver approval).

By December 31, enrollment in Montana’s expanded Medicaid had already reached 20,000 people, and their coverage became effective January 1. The state had projected 23,000 enrollees by mid-2016, and they more that doubled that amount, with 47,399 people enrolled in expanded Medicaid by July 2016.

Including Montana, 31 states plus the District of Columbia have accepted federal funding to expand Medicaid. Governor Steve Bullock’s office has estimated that there are still 9,000 uninsured veterans in Montana, many of whom have low incomes; the governor has touted expanded Medicaid as a good option for these veterans.

Expansion saves money for Montana

The state reported in July 2016 that the new enrollees had already received $75 million worth of healthcare services, all of which was paid for in full by the federal government. The state will begin to shoulder 5 percent of the cost starting in 2017, and will eventually pay 10 percent by 2020. Going forward, the 90/10 split between the federal and state government will remain steady, as will be the case in every state that has expanded Medicaid.

As of March 2016, when expansion coverage had only been in effect for less than three months, Montana officials reported that the state had already saved the state’s general fund $3 million, because some of the newly insured Medicaid beneficiaries were people for whom the state used to pay a portion of their health care costs; those costs were borne instead by the federal government starting in 2016.

Montana’s Medicaid expansion waiver calls for enrollees to pay 2 percent of their income in premiums, which the state says average about $31 per month. As of March, they had collected about 68 percent of the premiums that were due by that point.


Montana agrees to expand Medicaid

On April 29, 2015, Montana Governor Steve Bullock signed Senate Bill 405 into law. The legislation called for Medicaid expansion for all adults with incomes up to 138 percent of poverty (children were already eligible for Medicaid or CHIP with household incomes in excess of that amount).

But proposal needed CMS approval

Any version of Medicaid expansion that places additional requirements or restrictions on enrollment must be granted a waiver from CMS in order to receive federal funding.  Montana’s legislation deviated from the straight Medicaid expansion called for in the ACA; bill sponsor Ed Buttrey (R – Great Falls) called it the “most conservative plan in the US.”

SB405 called for newly-eligible enrollees to pay 2 percent of their income in premiums, and it also imposes copays for some medical services. In addition, the legislation included a job training and workforce assessment program, aimed at helping enrollees secure a job or move into a better job (this aspect of the legislation was not included in the official waiver proposal that was submitted to CMS; that is clarified on page 26 of the waiver proposal, and was brought up as a concern in August by Montana Representative Art Wittich. Work and job training requirements have generally not been approved by CMS when included in other states’ Medicaid expansion proposals).

So although SB405 was the law of the land in Montana, the state still needed to get approval from CMS to proceed with their modified version of Medicaid expansion. On July 7, 2015, the state posted the waiver application and began a 60 day public comment period. Montana residents had an opportunity to comment on the proposal online, and there were two public meetings about the proposal in August.

On September 15, the state submitted their Medicaid Section 1115 demonstration waiver proposal to CMS for review. Official changes to Medicaid eligibility were dependent on federal funding for expansion, which required CMS approval of the state’s waiver. The state had asked CMS to approve the waiver by the beginning of November, and was hoping to have expanded Medicaid coverage available by January 2016. The waiver was approved on November 2, 2015. Expanded Medicaid coverage took effect in Montana on January 1, but eligible residents were able to begin enrolling immediately following the waiver approval.

70,000 newly eligible for coverage

Under the new guidelines, Medicaid coverage is newly-available for about 70,000 of Montana’s lowest-income residents. Officials expected about 45,000 of them to enroll in expanded Medicaid by 2020 (not everyone who is eligible ends up enrolling, even in states with straight expansion; in a state where there will be premiums – even small ones – assessed for Medicaid coverage, uptake will be far from universal), but by July 2016, enrollment had already exceeded 47,000 — that was more than the state expected to enroll by 2020, and it had happened within just the first several months of expanded eligibility.

Nearly 30,000 of the newly-eligible population (with incomes between 100 percent and 138 percent of poverty) are people who were previously eligible for subsidies in the exchange, but Medicaid provides them with much lower cost-sharing.

About 40,140 Montana residents had been in the coverage gap since the start of 2014, but they now have access to Medicaid coverage. Mostly adults without dependent children, or those with children who live a little below the poverty level, these individuals were not previously eligible for Medicaid in Montana, and they were also not eligible for premium subsidies because their income was too low. Subsidies are only available for people with incomes of at least 100 percent of poverty, because everyone below that level was supposed to get Medicaid. Medicaid expansion eliminates the coverage gap.

Blue Cross Blue Shield managing expansion program

While Montana’s Section 1115 waiver was being reviewed by CMS, the state completed the bidding process to find a private insurer to manage the Medicaid expansion program in the state. Blue Cross Blue Shield of Montana scored highest in the bidding process, and signed a contract in December to be the administrator for the expanded Medicaid program.

BCBS of Montana had been working on infrastructure even before the Medicaid expansion waiver was approved, and began focusing on outreach and consumer education once the waiver was approved.

Keeping Montana tax dollars in Montana

Because Montana didn’t initially expand Medicaid, it was projected that the state would miss out on $2.1 billion in federal funding from 2013 to 2022.  If the state had not expanded Medicaid, Montana residents would have paid $705 million in federal income taxes over the next eight years to fund Medicaid expansion in other states, while receiving no Medicaid expansion funds for their own state.

The federal government will pay the full cost of Medicaid expansion through 2016. After that, the state gradually pays a small portion of the cost, but it will never exceed 10 percent. Estimates vary, but over the next two years it’s expected that Montana’s share of the cost of Medicaid expansion will be somewhere in the range of $400 million to $700 million.

With coverage expansion in place, Montana is expected to save $11.5 million in the next two years, due to the fact that Medicaid expansion will eliminate the need to fund current programs for uninsured residents (by March 2016, the state reported that it had already saved $3 million). In 2018 and 2019, the state is expected to pay about $10 million and $17 million, respectively, to cover the state’s portion of the cost of Medicaid expansion (that pales in comparison to the more than two billion dollars the state will get in federal Medicaid expansion funding over the coming decade).

Governor, citizens pushed for expansion in 2015

Democratic Governor Steve Bullock has long supported Medicaid expansion, and a poll conducted by the Bozeman Chronicle in the spring of 2014 found that 74 percent of nearly a thousand respondents were in favor of Medicaid expansion.

In 2013, the Republican majority in the state legislature blocked measures to expand Medicaid following a design similar to what Arkansas has used, despite some bipartisan support.  Then in 2014, supporters of Medicaid expansion worked to get a Medicaid expansion initiative on the November 2014 ballot, but ultimately fell short in their signature collection process, announcing in June that they would not be able to gather the required number of signatures by the deadline.

Supporters of Medicaid expansion, including Governor Bullock and the Healthy Montana Campaign, vowed to renew the issue during the 2015 legislative session, and the bill that was ultimately signed into law in April 2015 was sponsored by a Republican (Ed Buttrey, a Senator from Great Falls).

Who is eligible for Montana Medicaid?

In addition to low-income elderly residents and those who are disabled, Medicaid is available to the following populations in Montana:

  • Pregnant women with household incomes up to 157% of poverty.
  • Adults with household income up to 138 percent of poverty (coverage effective dates will begin January 1, 2016; enrollment became available November 2, 2015)
  • Children are eligible for Medicaid if their household incomes are up to 143 percent of poverty.  Above that level, they are eligible for CHIP if their household incomes do not exceed 261 percent of poverty.
  • Cancer screening services are available to residents with household incomes up to 200 percent of poverty.

How do I apply?

  • You can apply at at any time – Medicaid enrollment is available year-round.
  • You can also apply online at anytime during the year.
  • You can also apply over the phone with by calling 1-800-318-2596.
  • You can apply in-person at any of Montana’s Offices of Public Assistance.
  • You can print a paper application and mail or deliver it to an Office of Public Assistance.  The application will determine your eligibility for a variety of public assistance programs in addition to Medicaid.

Montana Medicaid history

Medicaid became effective in Montana in July 1967, putting the state around the middle of the pack in terms of implementing the program.

As of June 2011, Montana’s Medicaid program was providing coverage for 60,800 children, 19,900 adults, 10,500 elderly, and 19,600 disabled residents. A total of 178,846 people had coverage in Montana’s Medicaid/CHIP prorams as of June 2015, which was an increase of 20 percent over the 148,974 people who had coverage at the end of 2013.

The increase occurred despite the fact that Montana’s Medicaid expansion didn’t take effect until 2016, due in part to several improvements the state had made to the Medicaid program over the preceding few years. In 2011 and 2012, payment rates for providers were increased. In 2011, the state expanded the existing eligibility rules, and also simplified the application and renewal process. And in both 2011 and 2012, Montana expanded the long term care portion of its Medicaid program.

By July 2016, after the expanded guidelines had been in place for several months, total Medicid/CHIP enrollment in Montana had grown to 239,250 people — a 61 percent increase since the end of 2013.