Plan First

• Annual Public Forum Handout for the Section 1115 Plan First Demonstration
• Public Input Forum Announcement – December 5, 2023
• Public Input Forum Announcement – November 29, 2022
• Public Input Forum Agenda for November 29, 2022 meeting
• Public Input Forum Plan First handout for November 29, 2022 meeting

• Plan First 2022 Annual Report
• Attachment A of Plan First 2022 Annual Report
• Plan First 2022 Budget Neutrality
• Plan First 2023 Budget Neutrality

If income is near the shown income guidelines, please apply. Some income may not be counted. This way we can help you find the best coverage for which you qualify.

2024 Income Thresholds are effective through March 31, 2025

The Administrative Rules of Montana (ARMs) can be found online at: https://rules.mt.gov/.

ARM 37.86.1707 1115 PLAN FIRST WAIVER  

1. "Plan First" refers to Montana's Social Security Act Section 1115 Waiver titled Plan First. This waiver is approved by the Centers for Medicare & Medicaid Services and managed by the Department of Public Health and Human Services (DPHHS) with eligibility determined by the Office of Public Assistance (OPA).
2. A woman may receive coverage through Plan First if they are not eligible for other Medicaid benefits and:
   1.  is a Montana resident;
   2. is aged 19 through 44 years;
   3. is able to become pregnant but is not currently pregnant; and
   4. has a household income up to 211% of the federal poverty level (FPL).
3. Except as otherwise provided in this rule, the limited Plan First benefits are available to all persons who are members of Plan First under this chapter.
4. Services covered under Plan First are limited to family planning and family planning-related services.
5. Plan First is a Medicaid program, and as a condition of participation in Montana Medicaid, all providers must comply with provider participation rules set forth in ARM 37.85.401 and the billing, reimbursement, claims processing, and payment provisions set forth in ARM 37.85.406.
6. The procedure billing codes specific to Plan First are available at the Medicaid provider website located at https://medicaidprovider.mt.gov/planfirst.
7. The Medicaid Program will not reimburse providers for services rendered to Plan First members for billing codes not listed on the website referred to in (6).
8. Providers are responsible for confirming Medicaid eligibility and for identifying Plan First members to ensure the provider seeks Medicaid reimbursement for only those services that are covered by Plan First.

ARM 37.82.701 GROUPS COVERED, NONINSTITUTIONALIZED FAMILIES AND CHILDREN

1. Medicaid will be provided to:
   1. Individuals under age 19 who currently reside in Montana and are receiving foster care, guardianship, or adoption assistance under Title IV-E of the Social Security Act, whether or not such assistance originated in Montana. Eligibility requirements for Title IV-E foster care and adoption assistance are found in ARM 37.50.101, 37.50.105, 37.50.106, and 45 CFR part 233.
   2. Individuals who have been receiving assistance in the nonmedically needy family Medicaid program and whose assistance is terminated because of earned income. These individuals may continue to receive Medicaid for any or all of the 6 calendar months immediately following the month in which nonmedically needy family Medicaid is last received, providing:
      1. in cases where assistance was terminated due to earned income, a member of the assistance unit continues to be employed during the 6 months; however, eligibility may continue even though no member of the assistance unit is employed if there was a good cause as defined in the family-related Medicaid Manual, section 1508-1, as incorporated by reference in ARM 37.82.101, for the termination or loss of employment;
      2. they received nonmedically needy family Medicaid for three of the six months immediately prior to the month they became ineligible for nonmedically needy family Medicaid coverage; and
      3. there continues to be an eligible child in the assistance unit. This coverage group is known as the "family-transitional."
   3. Individuals under age 19 who live with a specified caretaker relative as defined in the family-related Medicaid manual, section 201-1, as incorporated by reference in ARM 37.82.101, and who meet all other eligibility requirements.
   4. A pregnant woman whose pregnancy has been verified and whose family income and resources meet the requirements listed in ARM 37.82.1106, 37.82.1107, and 37.82.1110. This coverage group is known as the "qualified pregnant woman group." The unborn child shall be considered an additional member of the filing unit for purposes of determining eligibility.
   5. A pregnant woman whose pregnancy has been verified, whose family income does not exceed 157% of the federal poverty guidelines. This coverage group is known as the "pregnancy group."
      1. The unborn child shall be considered an additional member of the filing unit for purposes of determining eligibility.
      2. Newborn children are continuously eligible through the month of their first birthday, provided they continue to reside in Montana. This coverage group is known as the "child-newborn group."
   6. A pregnant woman during a period of presumptive eligibility.
      1. Presumptive eligibility is established by submission of an application by the applicant on the form specified by the department, to a qualified presumptive eligibility provider, verification of pregnancy and a determination by the qualified presumptive eligibility provider that applicant's household income and resources do not exceed the income and resource standards specified in (1)(e).
         1. A qualified presumptive eligibility provider is an entity which meets the requirements specified in section 3570 of the state Medicaid Manual, published by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and who is enrolled with the department as a qualified presumptive eligibility provider under the presumptive eligibility program. Section 3570 of the state Medicaid Manual is adopted and incorporated by this reference. A copy of the manual section may be obtained from the Department of Public Health and Human Services, Human and Community Services Division, 111 N. Jackson St., P.O. Box 202925, Helena, MT 59620-2925.
         2. Presumptive eligibility determinations shall be effective through the earlier of the date the department makes a determination of eligibility or ineligibility based upon a Medicaid application, or the last day of the month following the month of the presumptive eligibility determination, if no Medicaid application is filed within such period. An individual is limited to one presumptive eligibility period per pregnancy.
         3. The applicant or recipient shall be entitled to a fair hearing with respect to a determination by the department based upon a Medicaid application.
      2. During a period of presumptive eligibility, a pregnant woman is limited to ambulatory prenatal care services covered under the Montana Medicaid program. Such services may be provided by any Medicaid provider eligible to receive Medicaid reimbursement for such services under applicable law and regulations.
   7. A pregnant woman who becomes ineligible for Medicaid due solely to increased income and whose countable resources do not exceed $3,000 and whose pregnancy is disclosed to the department prior to the effective date of Medicaid closure. This coverage group is known as the "continuous pregnant woman group." Eligibility shall be continuous without lapse in Medicaid eligibility from the prior Medicaid eligibility and shall terminate on the last day of the month in which the 12-month postpartum period ends.
   8. A child who has not yet reached age 19, whose family income does not exceed 143% of the federal poverty guidelines. This coverage group is known as the "Healthy Montana Kids (HMK) Plus" group. Children determined eligible under the Healthy Montana Kids Plus program will receive up to 12 months of continuous coverage.
   9. Individuals under the age of 21 who are receiving foster care or subsidized adoption payments through child welfare services. These individuals must have full or partial financial responsibility assumed by public agencies and must have been placed in foster homes, private institutions, or private homes by a nonprofit agency.
   10. A child of a minor custodial parent when the custodial parent is living in the child's grandparent's home and the grandparent's income is the sole reason rendering the child ineligible for nonmedically needy family Medicaid.
   11. Needy caretaker relatives as defined in the family-related Medicaid Manual, section 201-1, as incorporated by reference in ARM 37.82.101, who have in their care an individual under age 19 who is eligible for Medicaid, and whose countable income does not exceed the state's family Medicaid standards as defined in the family-related Medicaid Manual, section 002.
   12. A child through the month of the child's 19th birthday, who lives in a household whose income exceeds the categorically needy standards and resources do not exceed the resource standards specified in ARM 37.82.1106, 37.82.1107, and 37.82.1110. This coverage group is known as the "family medically needy group."
   13. Individuals, under the age of 65 who have been screened through the Montana Breast and Cervical Health Program who:
       1. have been diagnosed with cancer or precancer of the breast or cervix;
       2. do not have creditable coverage to pay for their cancer/precancer treatment;
       3. have countable income that does not exceed 250% of the federal poverty level at the time of screening and enrollment into the Montana Breast and Cervical Health Program; and
       4. are not eligible for any other nonmedically needy Medicaid coverage group. This coverage group is known as "breast and cervical cancer treatment."
   14. Families who, due to receipt of new or increased spousal support, lose eligibility for nonmedically needy family Medicaid. To be eligible the family must:
       1. receive new or increased spousal support in an amount great enough to cause their nonmedically needy family Medicaid eligibility to end; and
       2. have received nonmedically needy family Medicaid in Montana for three of six months prior to the closure of nonmedically needy family Medicaid. The coverage will continue for four consecutive months. This program is known as the "family-extended group.
   15. Women ages 19 through 44, who have not been otherwise determined eligible for Medicaid under this title, who are able to become pregnant but are not now pregnant, whose household income does not exceed 211% of the federal poverty level. Services are limited to those family planning services defined at ARM 37.86.1707 and not covered by third party health coverage. This program is limited to 4,000 women at any given time and is known as Plan First. Plan First will not pay any copay or deductible required by a member's third party health coverage.
2. Medicaid will continue until the last day of the month in which the 12-month postpartum period ends for pregnant women as long as the pregnant woman was eligible for and receiving Medicaid on the date pregnancy ends.
3. Medicaid may be provided for up to three months prior to the date of application for individuals listed in (1)(a), (1)(c), (1)(d), (1)(g), (1)(h), (1)(i), (1)(j), (1)(k), (1)(l), and (1)(m) if all financial and nonfinancial eligibility criteria are met as of the date medical services were received in each of those months.