What Does Medicaid Cover in Montana? Benefits, Costs, and Limits

Montana Medicaid covers most medically necessary health care for enrolled members, including primary and specialist doctor visits, hospital care, emergency services, prescription drugs, dental and vision, hearing aids, mental health and substance use treatment, physical and occupational and speech therapy, durable medical equipment, nursing home care and home-based alternatives, non-emergency medical transportation, family planning, hospice, and home health. Coverage limits and copays depend on your age and which eligibility pathway you fall under, with children getting the broadest benefits and adults subject to some annual caps and exclusions.

Doctor, Hospital, and Clinic Care

The program pays for physician visits, inpatient and outpatient hospital care, emergency services, immunizations, lab work, and clinic services.¹ Obstetric care, midwife-attended homebirths, and well-child checkups are included, along with dialysis, respiratory therapy, transplants, home infusion therapy, and hospice.

Most members are enrolled in Passport to Health, Montana’s primary care case management system. You pick (or get assigned) a primary care provider who coordinates your care and issues referrals to specialists. Services given without a Passport referral generally won’t be paid for. Several categories are exempt from the referral requirement, though: emergency care, dental, mental health, pharmacy, family planning, vision, hearing, home and community-based services, substance use treatment, and transportation.²

Prescription Drugs

Montana Medicaid covers prescription medications, selected over-the-counter drugs, compounded prescriptions, and contraceptive supplies. The state keeps a Preferred Drug List that sorts medications into preferred and non-preferred categories. Non-preferred drugs typically require prior authorization and often a trial of a preferred alternative first.³

Prescriptions are generally limited to a 34-day supply, though certain maintenance drugs can be dispensed for up to 90 days. If two rebate-eligible generics are available, the state requires generic substitution; a brand name needs prior authorization unless it’s listed as preferred.³

Covered over-the-counter items include certain antihistamines, proton pump inhibitors, nicotine cessation products (patches, gum, lozenges), oral contraceptives, folic acid, insulin, steroid nasal sprays, and opioid reversal agents like naloxone.⁴ The program does not cover fertility drugs, erectile dysfunction medications, weight-loss drugs, cosmetic or hair-growth products, or drugs from manufacturers without a federal rebate agreement.³

Dental Services

Dental coverage looks very different depending on age. Children aged 20 and under receive nearly all medically necessary dental services with no annual spending cap. Exams and cleanings are available as often as medically necessary, and bridges, tooth-colored crowns, dentures, and orthodontia (with prior authorization) are covered.⁵

Adults have a $1,125 annual cap on dental treatment services, which covers fillings, crowns, root canals, periodontal work, and oral surgery. Diagnostic services, preventive care, dentures, and certain anesthesia services don’t count against the cap. Adults who qualify as Aged, Blind, or Disabled are exempt from the cap altogether.⁵ Adults get exams and cleanings every six months and are limited to two crowns per calendar year. Noble metal crowns, bridges, dental implants, cosmetic dentistry, and orthodontia for anyone 21 or older are excluded.⁶

Dentures are covered for both age groups. Partial dentures can be replaced every five years, full dentures every ten years, and Medicaid will cover one replacement for a lost set per lifetime.⁵

Vision and Hearing

Eye exams and eyeglasses are covered. Adults get one eye exam every 24 months and one pair of glasses every 12 months. Children get one exam every 12 months and glasses every 12 months, or more often when medically necessary. All glasses come through a state contract with Classic Optical Laboratories; if you pick frames or lenses outside the contract, you pay the difference. Most add-on features like photochromic or polycarbonate lenses aren’t covered for adults, though children can get them when medically necessary.⁷

Hearing aids are covered but require both a physician referral and prior authorization through Mountain Pacific Quality Health. Adults need a pure tone hearing loss of at least 40 decibels in the better ear to qualify for a monaural aid; the threshold for children is 25 decibels. Binaural aids for adults require documented use of a single hearing aid for at least six months, plus evidence of an educational or vocational need for improved comprehension. Replacement is limited to once every five years for adults aged 21 and older. Over-the-counter hearing aids aren’t covered.⁸

Mental Health and Substance Use Treatment

Behavioral health coverage is broad. The program pays for outpatient therapy (individual, family, and group), psychiatric rehabilitation, illness management and recovery programs, peer support, day treatment, and crisis stabilization. Coverage for the Program of Assertive Community Treatment, a team-based model for people with severe and persistent mental illness, was added effective in 2024.⁹

Crisis services include short-term crisis receiving (under 24 hours), crisis stabilization in residential settings, mobile crisis response teams that deploy without law enforcement, and follow-up crisis care coordination.⁹ Telehealth is permitted for behavioral health when clinically appropriate.

Substance use disorder treatment is covered through a network of approved providers, with targeted case management available for people with SUD.¹⁰ The Preferred Drug List includes addiction treatment medications such as buprenorphine products and naltrexone.¹¹

Two additional programs extend mental health coverage to people who might not otherwise qualify. The Waiver for Additional Services and Populations (WASP) provides standard Medicaid benefits, including mental health care, to adults with severe and disabling mental illness who don’t meet regular eligibility criteria. The Severe Disabling Mental Illness HCBS Waiver provides community-based daily living supports to help those individuals stay out of nursing facilities.¹²

Expanded Benefits for Children (EPSDT)

Children on Medicaid from birth through age 20 are covered under the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT). Well-child visits follow the Bright Futures schedule and include physical exams, developmental and mental health screenings, immunizations, blood lead testing, vision and oral health assessments, and health education.¹³

When a screening finds a problem, EPSDT requires that treatment be provided, even if the service wouldn’t normally be covered or would exceed standard adult limits. Services outside typical coverage can be approved case-by-case when a primary care provider or specialist determines they’re medically necessary.¹³ For therapy specifically, children aren’t subject to visit caps or hourly limits so long as the treatment is restorative.¹⁴

Physical, Occupational, and Speech Therapy

Therapies are covered for all members when restorative, meaning there’s a reasonable expectation of meaningful improvement within a predictable timeframe. Maintenance therapy — repetitive services to preserve function without expected improvement — is not covered.¹⁴

Therapy doesn’t need prior authorization but does need a written or verbal order from a physician or mid-level practitioner, valid for up to 180 days. Passport members also need their primary care provider’s referral approval. All three therapy types can be delivered by telehealth.¹⁴

Medical Equipment and Supplies

Montana Medicaid covers medically necessary durable medical equipment, prosthetics, orthotics, and medical supplies, using Medicare’s coverage criteria as the baseline. Prior authorization is required when an item costs $1,000 or more (based on the reimbursement amount) or has a manufacturer’s suggested retail price above $1,334.¹⁵

Specific rules apply to common items:

Wheelchairs are limited to one new chair every five years unless a significant change in medical condition requires earlier replacement.¹⁶
Breast pumps: one double electric pump per pregnancy (no more than one per year), available starting at 28 weeks gestation or while breastfeeding. Hospital-grade pump rentals are limited to two months unless extended through prior authorization.¹⁵
Blood glucose test strips and lancets are limited to 100 per three months for non-insulin-dependent members and 300 per three months for insulin-dependent members.¹⁵
Incontinence supplies: up to 180 disposable diapers and 240 underpads per month for eligible members aged three and older. Not covered for nursing facility residents.¹⁵

Items not covered include convenience and comfort products, exercise equipment, personal computers, building or automobile modifications, and orthopedic shoes unless attached to a brace or qualifying as diabetic therapeutic footwear.¹⁶

Long-Term Care and Home-Based Services

The program covers nursing home care and several home and community-based alternatives designed to help people stay in their communities. Three main HCBS waivers operate in Montana.¹⁷

Big Sky Waiver

The Big Sky Waiver serves individuals who meet nursing facility level-of-care criteria and are financially eligible for Medicaid. Covered services include adult residential living, adult day health, case management, personal assistance, respite, physical/occupational/speech therapy, transportation, and specialized medical equipment. Referrals go through Mountain Pacific Quality Health.¹⁸

Developmental Disabilities Waiver

The 0208 Waiver covers individuals of any age with intellectual or developmental disabilities who would otherwise require an intermediate care facility. Services range from residential habilitation and supported employment to personal care, respite, environmental modifications, behavioral support, private duty nursing, and transportation.¹⁹ Eligibility isn’t income-based but requires documentation of a condition that began before age 18 and causes significant developmental delays. For individuals aged eight and older, a documented IQ of roughly 70 or below plus functional limitations in daily living are required.²⁰ There’s a lengthy waitlist, with placement based mostly on how long someone has been waiting.

Community First Choice and Personal Care

Community First Choice Services and Personal Care Services cover help with daily activities such as bathing, dressing, grooming, toileting, eating, and medication assistance for members whose health conditions limit their ability to perform these tasks. Community First Choice requires a nursing home level of care and adds services like skill-building, community integration, and personal emergency response systems. You can choose agency-based care or hire and manage your own attendants through self-direction.¹⁸

Non-Emergency Medical Transportation

Montana Medicaid covers rides to and from covered medical appointments, but every trip requires prior authorization from the Medicaid Transportation Center (operated by Mountain Pacific Quality Health) before you travel. Trips taken without advance approval won’t be paid for.²¹

The program covers mileage reimbursement for personal vehicles, commercial ground and air transportation, taxis, buses, and specialized wheelchair or stretcher vans. Meals and overnight lodging are covered when you must stay overnight for medical services, with meal coverage beginning on the second day. You’re expected to use the least expensive mode suitable for your medical needs, and coverage isn’t available when the appointment is in your community and you have access to public transit, a personal vehicle, or a ride from someone you know.²²

Telehealth

All Montana Medicaid covered services can be delivered via telehealth when medically necessary, clinically appropriate for remote delivery, and not explicitly required to be face-to-face by the provider manual. Reimbursement rates match in-person rates, and there are no geographic or facility restrictions on where the provider is located.²³ Accepted modalities include live video, telephone, secure messaging, and audio-visual conversations, with no specific technology requirements.

Other Covered Services

Family planning: The Plan First waiver covers annual exams, contraceptives, STI testing and treatment, and related labs for women aged 19 to 44 with incomes up to 211 percent of the federal poverty level who aren’t otherwise Medicaid-eligible.²⁴
Chiropractic services are listed as a covered benefit under standard Medicaid.¹
Tobacco cessation is covered for all members, including counseling for pregnant women.¹
Interpreter services are available to members who need language assistance at medical appointments.¹
Hospice is covered for terminally ill individuals certified as having six months or fewer to live, including palliative care, counseling, drugs, equipment, and supplies related to the terminal illness.¹⁸
Home health covers intermittent nursing, therapy, home health aides, and medical supplies when ordered by a physician and renewed every 60 days.¹⁸

What You Pay

For most members, nothing. Montana eliminated copayments for all Medicaid and Medicaid Expansion covered services effective January 1, 2020, as required by HB 658. Members pay no copays for doctor visits, prescriptions, hospital care, or any other covered service.²⁵ Copayments still apply to children enrolled in the separate Healthy Montana Kids (CHIP) program administered by Blue Cross Blue Shield, and cost-share and spend-down requirements remain in place for Workers with Disabilities and Medically Needy enrollees.

Providers generally can’t bill you for the difference between their usual charge and the Medicaid-allowed amount. A provider may only bill you directly if you signed an Advanced Beneficiary Notice before the service, agreeing to pay privately for something that isn’t covered, isn’t medically necessary, is experimental, or wasn’t authorized.¹

What Montana Medicaid Does Not Cover

In addition to the service-specific limits noted above, Montana Medicaid doesn’t pay for experimental or investigational treatments, services that aren’t medically necessary, services performed in unapproved settings, or services received when you’re not eligible. For adults, notable exclusions include dental implants, cosmetic dentistry, bridges, noble metal crowns, and orthodontia.⁵ On the pharmacy side, fertility drugs, erectile dysfunction medications, weight-loss drugs, and cosmetic products are excluded.³ For equipment, convenience items, exercise gear, building modifications, and over-the-counter hearing aids fall outside the program.¹⁶

Services Requiring Prior Authorization

Some services need advance approval from the state or Mountain Pacific Quality Health before they’ll be paid for. These include transplants, out-of-state inpatient hospital stays, dental orthodontia, hearing aids, higher-cost durable medical equipment, home infusion therapy, certain surgical procedures (such as breast reconstruction, orthognathic surgery, and panniculectomy), genetic testing for BRCA-related cancer, and many non-preferred prescription drugs.²⁶ For prescriptions, decisions are typically made immediately, with cases needing peer review resolved within 24 hours, and an emergency 72-hour supply can be dispensed after hours or on weekends.³

New Work Requirements Starting in 2026

Federal legislation signed into law on July 4, 2025 (H.R. 1, the “One Big Beautiful Bill Act”) adds new requirements for Medicaid expansion enrollees. In Montana, adults aged 19 to 64 on expansion Medicaid will have to complete 80 hours per month of qualifying activities beginning in July 2026. Qualifying activities include employment, volunteering, workforce training through the state, internships or apprenticeships, and attending school at least half-time.²⁷

Compliance will be checked at initial application and at six-month renewal intervals through data matching or self-reported documentation like pay stubs, school transcripts, or signed volunteer logs. From July through September 2026, Montana will review compliance but won’t disenroll anyone for failing to meet the requirements. Starting in October 2026, non-compliance may result in denial of coverage or disenrollment.²⁸

Exemptions apply to American Indian and Alaska Native individuals, pregnant or postpartum women, parents and caregivers of children under 13 or of people with disabilities, veterans with total disability ratings, individuals who are medically frail, people in substance use disorder treatment, and those currently incarcerated or recently released.²⁷ Beginning January 2027, most expansion enrollees will also face eligibility redeterminations every six months rather than every 12 months, though American Indian and Alaska Native members will stay on annual renewals.²⁸

Further federal changes scheduled for later years include mandatory cost sharing for expansion adults with incomes above 100 percent of the federal poverty level starting in October 2028, capped at $35 per service or five percent of individual income, and a reduction of the retroactive eligibility window from 90 days to 30 days beginning in January 2027.²⁹ If you receive an adverse eligibility decision, you can appeal through a fair hearing.²⁷

1
Montana DPHHS. Montana Medicaid Member Guide
2
Montana DPHHS. What Is Passport to Health
3
Montana DPHHS. Prescription Drug Program Manual
4
Montana DPHHS. Pharmacy Provider Information
5
Montana DPHHS. Dental Services
6
Montana DPHHS. Dental and Denturist Program Manual
7
Montana DPHHS. Eye Care Services
8
Montana DPHHS. Audiology and Hearing Aid Services Manual
9
Medicaid.gov. Montana State Plan Amendment 24-0001
10
Montana DPHHS. Behavioral Health Provider Information
11
Montana DPHHS. Montana Preferred Drug List
12
Montana DPHHS. Mental Health Services
13
Montana DPHHS. Well-Child Checkups and EPSDT
14
Montana DPHHS. Therapy Services Manual
15
Montana DPHHS. DMEPOS Manual
16
Montana Administrative Rule. Mont. Admin. R. 37.86.1802
17
Montana DPHHS. Home and Community-Based Services
18
Montana DPHHS. Senior and Long-Term Care Community Services
19
Medicaid.gov. Montana DD Waiver Factsheet
20
Montana DPHHS. DDP 0208 Waiver Services
21
Montana DPHHS. Montana Healthcare Transportation
22
Montana DPHHS. Non-Emergency Transportation Services Manual
23
Montana DPHHS. Coverage and Reimbursement Policy for Telemedicine and Telehealth
24
Montana DPHHS. Plan First
25
Montana DPHHS. Copayment Elimination FAQ
26
Montana DPHHS. Prior Authorization
27
Montana DPHHS. Medicaid Changes
28
Montana DPHHS. Medicaid Changes FAQ
29
Montana State Legislature. H.R. 1 and Federal Action Impact Memo