Montana Medicaid and Healthy Montana Kids (HMK) Plus
Montana Medicaid and HMK Plus are healthcare benefits for eligible low-income Montanans. Montana Medicaid and HMK Plus pays for services that are:
- Medically necessary,
- Provided by a Montana Medicaid/HMK Plus enrolled provider, and
- Medicaid/HMK Plus covered services.
Changes to Copayments Effective June 1, 2016
Changes to Benefits and Copayments Effective January 1, 2016
Member Education (Newsletters and Presentations
Are you eligible?
Montana Medicaid and HMK Plus Member Information
Passport to Health (Passport): Choose your primary care provider
Passport is the primary care case management (PCCM) program for Montana Medicaid and HMK Plus members. The Passport programs support Medicaid and HMK Plus members, as well as, providers to establish a strong doctor/patient relationship and ensure the appropriate use of services.
As part of Passport, you are also enrolled in the Health Improvement Program. Depending on your health, you may be contacted by a care manager who can help you with health issues.
- You can choose your Passport provider anytime online.
- If you do not choose a Passport provider, you will be assigned one.
- If you need help choosing your Passport provider or have questions regarding Passport, call the Medicaid/HMK Plus Member Help Line at 1-800-362-8312, M-F, 8am-5pm.
- Remember, you will need a referral (approval) from your Passport provider before you can see most other healthcare providers.
- For more Passport information, see the Passport Section of the Member Guide.
What do I need to pay?
Copayments Effective June 1, 2016
A copayment is a payment owed by you to your healthcare provider for healthcare services that you receive.
The following copayments are for Montana Medicaid members with annual household incomes that fall below 100% Federal Poverty Level (FPL):
- $4 for outpatient services
- $75 for inpatient services
- $4 for pharmacy - preferred brand drugs
- $8 for pharmacy - non-preferred brand drugs
The following are for Montana Medicaid members with annual household incomes at or above 100% Federal Poverty Level (FPL):
Members with annual household incomes above 100% of the FPL will be responsible for a 10% copayment of the provider’s reimbursed amount for any Medicaid covered service. Except for pharmacy, which will be at:
- $4 for pharmacy – preferred brand drugs
- $8 for pharmacy – non-preferred brand drugs
In addition, copayments are not to be charged or made until the claim has been processed and the provider has been notified of payment and the member amount owed. Then you will be accurately billed by your provider. Providers cannot deny services for members below 100% FPL. You are still responsible for paying any copayments owed.
Services with No Copayment
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT),
- Emergencies in the Emergency Room (ER),
- Eyeglasses purchased by the Medicaid program under a volume purchasing arrangement,
- Family planning,
- Generic drugs,
- Home and Community Based Waiver services,
- Hospice services,
- Provider preventable healthcare acquired conditions,
- Some preventive services, and
- Services where Medicaid is the secondary payor. If a service is not covered by the primary payor but is covered by Medicaid, copayment will be applied.
Members Not Responsible for Copayment
- American Indians/Alaska Natives, who are eligible for or have received a service from a Tribal Health or Urban Health, or Indian Health Service (IHS) provider,
- Members under 21 years of age,
- Members in an inpatient hospital, skilled nursing facility, intermediate care facility, or other medical institution who are required to spend for the cost of care,
- Members whom are terminally ill receiving hospice services,
- Members receiving services under the Medicaid breast/cervical cancer treatment, and
- Pregnant women.
Maximum Out-of-Pocket Costs
Copayments may not exceed a combined limit of 5% of the family’s household income quarterly. Copayments may not be applied once the household has met the quarterly cap.
What are the Benefits?
- Dental care,
- Doctor, hospital, and emergency services,
- Family planning,
- Home health services,
- Laboratory and x-ray services,
- Maternity and newborn care,
- Mental health and substance abuse treatment,
- Nurse First Advice Line,
- Prescription drugs,
- Rehabilitative services and supplies,
- School-based services,
- Speech therapy, audiology, and hearing aids,
- Transportation to appointments, and
- Vision care.
- Preventative (cleaning, fluoride),
- Removable prosthodontics (dentures),
- Anesthesia/sedation services, and
- Dental emergency services as a result of an accident.
In addition to the benefits above, the following treatment services will also be available, subject to an annual cap of $1,125. Members excluded from this annual cap are: age 20 and under and members categorically aged, blind, or disabled. However, service limits may apply. The benefit year runs from July 1 through June 30. You will have to pay for services that go over the $1,125 dental treatment limit for the following list of treatments:
- Restorative (fillings, crowns),
- Endodontics (root canals),
- Periodontal (gum disease issues), and
- Oral surgery (extractions).
- Annual exam once every year, and
- Eyeglasses/eyewear once every year (depending on change in the prescription).
Many prescription drugs are covered. Some prescription drugs may need prior authorization. To find out if a drug you need is covered or to find out if a drug needs prior authorization, talk to your pharmacist or the person who prescribed the drug.
Medicaid will pay for a 34-day supply of drugs. Members may get a 90-day supply of some drugs at the time for heart disease, high blood pressure, or birth control. Early refills may be authorized if the person who writes the prescription changes your dose. Early refills cannot be granted for lost or stolen medication, or for vacation or travel.
Prescription drugs are only covered if you go to a Medicaid-enrolled pharmacy.
Member Rights and Responsibilities
Missed or Canceled Appointments
When members do not show up for a scheduled appointment, it creates an unused appointment slot that could have been used for another member. It is very important to keep appointments and call the provider in advance if you cannot make it to a scheduled appointment. Medicaid providers cannot bill a member for no-show/missed appointments. However, a provider may discharge a member from their practice after so many no-show/missed appointments. The provider must have the same policy for Medicaid members as non-Medicaid members, and must notify Medicaid members that the policy exists.
For a full list of member rights and responsibilities, see the Member Rights and Responsibilities Section of the Member Guide
Do you still have questions?
Here is a copy of the Montana Medicaid and Healthy Montana Kids Plus Member Guide. Be sure to check the announcements section above for information on changes to your benefits.
Need help finding your local Office of Public Assistance, Enrolled Medicaid Provider, or Passport Provider? Call Montana Healthcare Programs, Member Help Line 1-800-362-8312, M-F, 8am-5pm, for assistance.
Find a Montana Medicaid Provider.
Choose a Passport Provider.
Find a Montana Medicaid or HMK Plus Dental Provider.
Report a change for your case or apply for healthcare coverage.
View details about your case.
I lost my Medicaid/HMK Plus Card, call 1-888-706-1535 for a replacement.
Important Contact Numbers
Public Assistance Help Line
Eligibility and reporting changes to your case
Medicaid/HMK Plus, Member Help Line
Medical Benefits, copayments, and Passport to Health questions
Nurse First Advice Line
Talk to a nurse 24 hours a day, 7 days a week
Medicaid Transportation Services
Contact the Medicaid Transportation Center