Hospital and Clinic Settings
Services you get in a hospital, whether you stay in the hospital overnight or not, are covered. Some examples of services you might get in a hospital are:
- Emergency room services
- Medical services for which your provider admits you to the hospital
- Physical therapy
- Lab services
- Cardiac rehabilitation
- Pulmonary rehabilitation
Many hospital services must be prior authorized before you go to the hospital.
Doctor Visits/Surgery/Ancillary Services
All Medicaid eligible individuals have access to services provided by physicians and midlevel providers. Medicaid reimburses for services including, but not limited to: office visits, lab tests, x-rays, surgeries, childbirth, prenatal care and anesthesia
Immunizations are available based on the schedule provided by the Center for Disease Control.
- Immunizations for children ages 18 and under are available through the Vaccine for Children (VFC) program. If your primary care physician is a VFC provider, immunizations can be received at their office. Vaccines are also available at a Public Health Clinic.
- Adult immunizations are available from your primary care provider or at a Public Health Clinic.
Family Planning Services
Most family planning services are covered, including, but not limited to: physical exams with breast exams, pap test (to test for pre-cancerous conditions), pregnancy tests, birth control, sexual health counseling (how to prevent unintended pregnancy and sexually transmitted infections), testing and treatment for sexually transmitted infections, shots for German measles, shots for HPV, sterilization information and counseling. Sterilization is covered for people who are mentally competent and 21 years old or older at the time the consent form is signed. The consent form must be signed by the patient at least 30 days before the scheduled sterilization.
Durable Medical Equipment
Durable medical equipment is covered. Some services require prior authorization. Ask your medical provider or your DME provider if you are eligible.
Three types of therapy are covered, occupational therapy, physical therapy, and speech therapy. Therapy services must be ordered by your primary care physician and can occur whether you are in a hospital or are an outpatient.
Hearing aids, repairs and some related items are covered. A hearing aid must be ordered by your provider. The person who sells the hearing aid must get prior authorization and be an enrolled Montana Medicaid provider. All audiology services must be referred by a physician or midlevel practitioner.
You may need to get medical services outside of Montana.
If you have an accident, crisis or something that cannot wait until you’re back in Montana, seek help at a hospital. The out of-state hospital must accept you as a Montana Medicaid Member prior to you receiving services and become a Montana Medicaid or HMK Plus provider if they are not already, in order to get paid by Montana Medicaid. Otherwise, you will be responsible for payment.
All out-of-state hospital inpatient services need prior authorization. Other Medicaid and HMK Plus services may require prior authorization as shown in your member guide.
If you have Passport, you need your doctor’s approval for services as shown in the member guide.
Services received outside the United States, including Canada or Mexico, are never covered.
Urgent Care Services
Services you receive at an urgent care center may be covered if the center accepts Medicaid. If you have Passport, be sure to obtain a referral from your doctor if you go to an urgent care center.
Remember to always...
Check your Member Guide or Program Handbook for covered and non-covered services or call the Montana Healthcare Programs Member Helpline for more information regarding your healthcare benefits (800) 362-8312.
Make sure your providers are enrolled in the Montana Medicaid Healthcare program.
Get Passport referral from your primary care provider when required. Approximately 70% of all members covered by Montana Medicaid Healthcare Programs are enrolled in the Passport to Health Program or Team Care.