Revise medicaid buy-in program to include children with disabilities

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AN ACT REVISING THE MEDICAID BUY-IN PROGRAM TO INCLUDE CHILDREN WITH DISABILITIES;
PROVIDING AN APPROPRIATION; EXTENDING RULEMAKING AUTHORITY; AMENDING SECTIONS 53-6-
113, 53-6-131, AND 53-6-195, MCA; AND PROVIDING AN EFFECTIVE DATE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA:
Section 1. Section 53-6-113, MCA, is amended to read:
"53-6-113. Department to adopt rules. (1) The department shall adopt appropriate rules necessary
for the administration of the Montana medicaid program as provided for in this part and that may be required by
federal laws and regulations governing state participation in medicaid under Title XIX of the Social Security Act,
42 U.S.C. 1396, et seq., as amended.
(2) The department shall adopt rules that are necessary to further define for the purposes of this
part the services provided under 53-6-101 and to provide that services being used are medically necessary and
that the services are the most efficient and cost-effective available. The rules may establish the amount, scope,
and duration of services provided under the Montana medicaid program, including the items and components
constituting the services.
(3) The department shall establish by rule the rates for reimbursement of services provided under
this part. The department may in its discretion set rates of reimbursement that it determines necessary for the
purposes of the program. In establishing rates of reimbursement, the department may consider but is not
limited to considering:
(a) the availability of appropriated funds;
(b) the actual cost of services;
(c) the quality of services;
(d) the professional knowledge and skills necessary for the delivery of services; and
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(e) the availability of services.
(4) The department shall specify by rule those professionals who may:
(a) deliver or direct the delivery of particular services; and
(b) deliver services by means of telehealth in accordance with 53-6-122.
(5) The department may provide by rule for payment by a recipient of a portion of the
reimbursements established by the department for services provided under this part.
(6) (a) The department may adopt rules consistent with this part to govern eligibility for the
Montana medicaid program, including the medicaid buy-in program provided for in 53-6-195. Rules may include
but are not limited to financial standards and criteria for income and resources, treatment of resources,
nonfinancial criteria, family responsibilities, residency, application, termination, definition of terms, confidentiality
of applicant and recipient information, and cooperation with the state agency administering the child support
enforcement program under Title IV-D of the Social Security Act, 42 U.S.C. 651, et seq.
(b) The department may not apply financial criteria below $15,000 for resources other than income
in determining the eligibility of a child under 19 years of age for poverty level-related children's medicaid
coverage groups, as provided in 42 U.S.C. 1396a(l)(1)(B) through (l)(1)(D).
(c) The department may not apply financial criteria below $15,000 for an individual and $30,000 for
a couple for resources other than income in determining the eligibility of individuals for under 53-6-195 for the
medicaid buy-in program for workers with disabilities provided for in 53-6-195.
(d) (i) The department may not adopt rules or policies requiring a person who is eligible for
medicaid pursuant to 53-6-131(1)(e)(ii)(A) to:
(A) make only a cash payment to qualify for medicaid under that subsection; or
(B) only incur medical expenses as a means of qualifying for medicaid under that subsection.
(ii) If a person eligible for medicaid under 53-6-131(1)(e)(ii)(A) is participating in a home and
community-based services waiver, the department shall count as an eligible medical expense any medical
service or item that a nonwaiver medicaid member is allowed to count as a medical expense to qualify for
medicaid under 53-6-131(1)(e)(ii)(A).
(iii) Nothing in this subsection (6)(d) may be construed as preventing a person from making only a
cash payment to qualify for medicaid pursuant to 53-6-131(1)(e)(ii)(A).
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(7) The department may adopt rules limiting eligibility based on criteria more restrictive than that
provided in 53-6-131 if required by Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be
amended, or if funds appropriated are not sufficient to provide medical care for all eligible persons.
(8) The department may adopt rules necessary for the administration of medicaid managed care
systems. Rules to be adopted may include but are not limited to rules concerning:
(a) participation in managed care;
(b) selection and qualifications for providers of managed care; and
(c) standards for the provision of managed care.
(9) Subject to subsection (6), the department shall establish by rule income limits for eligibility for
extended medical assistance of persons receiving section 1931 medicaid benefits, as defined in 53-4-602, who
lose eligibility because of increased income to the assistance unit, as that term is defined in the rules of the
department, as provided in 53-6-134, and shall also establish by rule the length of time for which extended
medical assistance will be provided. The department, in exercising its discretion to set income limits and
duration of assistance, may consider the amount of funds appropriated by the legislature.
(10) Unless required by federal law or regulation, the department may not adopt rules that exclude a
child from medicaid services or require prior authorization for a child to access medicaid services if the child
would be eligible for or able to access the services without prior authorization if the child was not in foster care."
Section 2. Section 53-6-131, MCA, is amended to read:
"53-6-131. (Temporary) Eligibility requirements. (1) Medical assistance under the Montana
medicaid program may be granted to a U.S. citizen or a qualified alien as defined in 8 U.S.C. 1641 who is
determined by the department of public health and human services to be a Montana resident and, in its
discretion, to be eligible as follows:
(a) The person receives or is considered to be receiving supplemental security income benefits
under Title XVI of the Social Security Act, 42 U.S.C. 1381, et seq., and does not have income or resources in
excess of the applicable medical assistance limits.
(b) The person would be eligible for assistance under the program described in subsection (1)(a) if
that person were to apply for that assistance.
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(c) The person is in a medical facility that is a medicaid provider and, but for residence in the
facility, the person would be receiving assistance under the program in subsection (1)(a).
(d) The person is:
(i) under 21 years of age and in foster care under the supervision of the state or was in foster care
under the supervision of the state and has been adopted as a child with special needs; or
(ii) under 18 years of age and is in a guardianship subsidized by the department pursuant to 41-3-
444.
(e) The person meets the nonfinancial criteria of the categories in subsections (1)(a) through (1)(d)
and:
(i) the person's income does not exceed the income level specified for federally aided categories
of assistance and the person's resources are within the resource standards of the federal supplemental security
income program; or
(ii) the person, while having income greater than the medically needy income level specified for
federally aided categories of assistance:
(A) has an adjusted income level, after incurring medical expenses, that does not exceed the
medically needy income level specified for federally aided categories of assistance or, alternatively, has paid in
cash to the department the amount by which the person's income exceeds the medically needy income level
specified for federally aided categories of assistance; and
(B) (I) in the case of a person who meets the nonfinancial criteria for medical assistance because
the person is aged, blind, or disabled, has resources that do not exceed the resource standards of the federal
supplemental security income program; or
(II) in the case of a person who meets the nonfinancial criteria for medical assistance because the
person is pregnant, is an infant or child, or is the caretaker of an infant or child, has resources that do not
exceed the resource standards adopted by the department.
(f) The person is a qualified pregnant woman or a child as defined in 42 U.S.C. 1396d(n).
(g) The person is under 19 years of age and lives with a family having a combined income that
does not exceed 185% of the federal poverty level. The department may establish lower income levels to the
extent necessary to maximize federal matching funds provided for in 53-4-1104.
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(2) The department shall require an applicant to provide proof of the applicant's residency in this
state.
(3) (a) The department may establish income and resource limitations. Limitations of income and
resources must be within the amounts permitted by federal law for the medicaid program. Any otherwise
applicable eligibility resource test prescribed by the department does not apply to enrollees in the healthy
Montana kids plan provided for in 53-4-1104.
(b) The department may not count as a resource an individual retirement account that was
established by a person participating in the medicaid buy-in program for workers with disabilities provided for in
53-6-195 if:
(i) the person is no longer eligible for coverage under 53-6-195; and
(ii) the individual retirement account was established during the time the person was eligible for,
under 53-6-195, and receiving benefits through the medicaid program for workers with disabilities.
(4) (a) The department may not require a person who is eligible for medicaid under subsection
(1)(e)(ii)(A) to:
(i) make only a cash payment to qualify for medicaid under that subsection; or
(ii) only incur medical expenses as a means of qualifying for medicaid under that subsection.
(b) If a person eligible for medicaid under subsection (1)(e)(ii)(A) is participating in a home and
community-based services waiver, the department shall count as an eligible medical expense any medical
service or item that a nonwaiver medicaid applicant is allowed to count as a medical expense to qualify for
medicaid under subsection (1)(e)(ii)(A).
(c) Nothing in this subsection (4) may be construed as preventing a person from making only a
cash payment to qualify for medicaid pursuant to subsection (1)(e)(ii)(A).
(5) The Montana medicaid program shall pay, as required by federal law, the premiums necessary
for medicaid-eligible persons participating in the medicare program and may, within the discretion of the
department, pay all or a portion of the medicare premiums, deductibles, and coinsurance for a qualified
medicare-eligible person or for a qualified disabled and working individual, as defined in section 6408(d)(2) of
the federal Omnibus Budget Reconciliation Act of 1989, Public Law 101-239, who:
(a) has income that does not exceed income standards as may be required by the Social Security
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Act; and
(b) has resources that do not exceed standards that the department determines reasonable for
purposes of the program.
(6) The department may pay a medicaid-eligible person's expenses for premiums, coinsurance,
and similar costs for health insurance or other available health coverage, as provided in 42 U.S.C. 1396b(a)(1).
(7) In accordance with waivers of federal law that are granted by the secretary of the U.S.
department of health and human services, the department of public health and human services may grant
eligibility for basic medicaid benefits as described in 53-6-101 to an individual receiving section 1931 medicaid
benefits, as defined in 53-4-602, as the specified caretaker relative of a dependent child under the section 1931
medicaid program. A recipient who is pregnant, meets the criteria for disability provided in Title II of the Social
Security Act, 42 U.S.C. 416, et seq., or is less than 21 years of age is entitled to full medicaid coverage, as
provided in 53-6-101.
(8) The department, under the Montana medicaid program, may provide, if a waiver is not
available from the federal government, medicaid and other assistance mandated by Title XIX of the Social
Security Act, 42 U.S.C. 1396, et seq., as may be amended, and not specifically listed in this part to categories
of persons that may be designated by the act for receipt of assistance.
(9) Notwithstanding any other provision of this chapter, medical assistance must be provided to
infants and pregnant women whose family income does not exceed income standards adopted by the
department that comply with the requirements of 42 U.S.C. 1396a(l)(2)(A)(i) and whose family resources do not
exceed standards that the department determines reasonable for purposes of the program.
(10) Subject to appropriations, the department may cooperate with and make grants to a nonprofit
corporation that uses donated funds to provide basic preventive and primary health care medical benefits to
children whose families are ineligible for the Montana medicaid program and who are ineligible for any other
health care coverage, are under 19 years of age, and are enrolled in school if of school age.
(11) A person described in subsection (9) must be provided continuous eligibility for medical
assistance, as authorized in 42 U.S.C. 1396a(e)(5) through (e)(7).
(12) Full medical assistance under the Montana medicaid program may be granted to an individual
during the period in which the individual requires treatment of breast or cervical cancer, or both, or of a
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precancerous condition of the breast or cervix, if the individual:
(a) has been screened for breast and cervical cancer under the Montana breast and cervical
health program funded by the centers for disease control and prevention program established under Title XV of
the Public Health Service Act, 42 U.S.C. 300k, or in accordance with federal requirements;
(b) needs treatment for breast or cervical cancer, or both, or a precancerous condition of the
breast or cervix;
(c) is not otherwise covered under creditable coverage, as provided by federal law or regulation;
(d) is not eligible for medical assistance under any mandatory categorically needy eligibility group;
and
(e) has not attained 65 years of age.
(13) Subject to the limitation in 53-6-195, the department shall provide medicaid coverage to
workers and children with disabilities as provided in 53-6-195 and in accordance with 42 U.S.C.
1396a(a)(10)(A)(ii)(XIII), (a)(10)(A)(ii)(XIX), (cc), and (r)(2) and 42 U.S.C. 1396o.
(14) Nothing in subsection (1) may be construed as allowing the department to deny enrollment for
a reason that is impermissible under federal law or regulation. (Terminates June 30, 2025, on occurrence of
contingency--sec. 48, Ch. 415, L. 2019.)
53-6-131. (Effective on occurrence of contingency) Eligibility requirements. (1) Medical
assistance under the Montana medicaid program may be granted to a person who is determined by the
department of public health and human services, in its discretion, to be eligible as follows:
(a) The person receives or is considered to be receiving supplemental security income benefits
under Title XVI of the Social Security Act, 42 U.S.C. 1381, et seq., and does not have income or resources in
excess of the applicable medical assistance limits.
(b) The person would be eligible for assistance under the program described in subsection (1)(a) if
that person were to apply for that assistance.
(c) The person is in a medical facility that is a medicaid provider and, but for residence in the
facility, the person would be receiving assistance under the program in subsection (1)(a).
(d) The person is:
(i) under 21 years of age and in foster care under the supervision of the state or was in foster care
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under the supervision of the state and has been adopted as a child with special needs; or
(ii) under 18 years of age and is in a guardianship subsidized by the department pursuant to 41-3-
444.
(e) The person meets the nonfinancial criteria of the categories in subsections (1)(a) through (1)(d)
and:
(i) the person's income does not exceed the income level specified for federally aided categories
of assistance and the person's resources are within the resource standards of the federal supplemental security
income program; or
(ii) the person, while having income greater than the medically needy income level specified for
federally aided categories of assistance:
(A) has an adjusted income level, after incurring medical expenses, that does not exceed the
medically needy income level specified for federally aided categories of assistance or, alternatively, has paid in
cash to the department the amount by which the person's income exceeds the medically needy income level
specified for federally aided categories of assistance; and
(B) (I) in the case of a person who meets the nonfinancial criteria for medical assistance because
the person is aged, blind, or disabled, has resources that do not exceed the resource standards of the federal
supplemental security income program; or
(II) in the case of a person who meets the nonfinancial criteria for medical assistance because the
person is pregnant, is an infant or child, or is the caretaker of an infant or child, has resources that do not
exceed the resource standards adopted by the department.
(f) The person is a qualified pregnant woman or a child as defined in 42 U.S.C. 1396d(n).
(g) The person is under 19 years of age and lives with a family having a combined income that
does not exceed 185% of the federal poverty level. The department may establish lower income levels to the
extent necessary to maximize federal matching funds provided for in 53-4-1104.
(2) (a) The department may establish income and resource limitations. Limitations of income and
resources must be within the amounts permitted by federal law for the medicaid program. Any otherwise
applicable eligibility resource test prescribed by the department does not apply to enrollees in the healthy
Montana kids plan provided for in 53-4-1104.
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(b) The department may not count as a resource an individual retirement account that was
established by a person participating in the medicaid buy-in program for workers with disabilities provided for in
53-6-195 if:
(i) the person is no longer eligible for coverage under 53-6-195; and
(ii) the individual retirement account was established during the time the person was eligible for,
under 53-6-195, and receiving benefits through the medicaid program for workers with disabilities.
(3) The Montana medicaid program shall pay, as required by federal law, the premiums necessary
for medicaid-eligible persons participating in the medicare program and may, within the discretion of the
department, pay all or a portion of the medicare premiums, deductibles, and coinsurance for a qualified
medicare-eligible person or for a qualified disabled and working individual, as defined in section 6408(d)(2) of
the federal Omnibus Budget Reconciliation Act of 1989, Public Law 101-239, who:
(a) has income that does not exceed income standards as may be required by the Social Security
Act; and
(b) has resources that do not exceed standards that the department determines reasonable for
purposes of the program.
(4) (a) The department may not require a person who is eligible for medicaid under subsection
(1)(e)(ii)(A) to:
(i) make only a cash payment to qualify for medicaid under that subsection; or
(ii) only incur medical expenses as a means of qualifying for medicaid under that subsection.
(b) If a person eligible for medicaid under subsection (1)(e)(ii)(A) is participating in a home and
community-based services waiver, the department shall count as an eligible medical expense any medical
service or item that a nonwaiver medicaid applicant is allowed to count as a medical expense to qualify for
medicaid under subsection (1)(e)(ii)(A).
(c) Nothing in this subsection (4) may be construed as preventing a person from making only a
cash payment to qualify for medicaid pursuant to subsection (1)(e)(ii)(A).
(5) The department may pay a medicaid-eligible person's expenses for premiums, coinsurance,
and similar costs for health insurance or other available health coverage, as provided in 42 U.S.C. 1396b(a)(1).
(6) In accordance with waivers of federal law that are granted by the secretary of the U.S.
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department of health and human services, the department of public health and human services may grant
eligibility for basic medicaid benefits as described in 53-6-101 to an individual receiving section 1931 medicaid
benefits, as defined in 53-4-602, as the specified caretaker relative of a dependent child under the section 1931
medicaid program. A recipient who is pregnant, meets the criteria for disability provided in Title II of the Social
Security Act, 42 U.S.C. 416, et seq., or is less than 21 years of age is entitled to full medicaid coverage, as
provided in 53-6-101.
(7) The department, under the Montana medicaid program, may provide, if a waiver is not
available from the federal government, medicaid and other assistance mandated by Title XIX of the Social
Security Act, 42 U.S.C. 1396, et seq., as may be amended, and not specifically listed in this part to categories
of persons that may be designated by the act for receipt of assistance.
(8) Notwithstanding any other provision of this chapter, medical assistance must be provided to
infants and pregnant women whose family income does not exceed income standards adopted by the
department that comply with the requirements of 42 U.S.C. 1396a(l)(2)(A)(i) and whose family resources do not
exceed standards that the department determines reasonable for purposes of the program.
(9) Subject to appropriations, the department may cooperate with and make grants to a nonprofit
corporation that uses donated funds to provide basic preventive and primary health care medical benefits to
children whose families are ineligible for the Montana medicaid program and who are ineligible for any other
health care coverage, are under 19 years of age, and are enrolled in school if of school age.
(10) A person described in subsection (8) must be provided continuous eligibility for medical
assistance, as authorized in 42 U.S.C. 1396a(e)(5) through (e)(7).
(11) Full medical assistance under the Montana medicaid program may be granted to an individual
during the period in which the individual requires treatment of breast or cervical cancer, or both, or of a
precancerous condition of the breast or cervix, if the individual:
(a) has been screened for breast and cervical cancer under the Montana breast and cervical
health program funded by the centers for disease control and prevention program established under Title XV of
the Public Health Service Act, 42 U.S.C. 300k, or in accordance with federal requirements;
(b) needs treatment for breast or cervical cancer, or both, or a precancerous condition of the
breast or cervix;
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(c) is not otherwise covered under creditable coverage, as provided by federal law or regulation;
(d) is not eligible for medical assistance under any mandatory categorically needy eligibility group;
and
(e) has not attained 65 years of age.
(12) Subject to the limitation in 53-6-195, the department shall provide medicaid coverage to
workers and children with disabilities as provided in 53-6-195 and in accordance with 42 U.S.C.
1396a(a)(10)(A)(ii)(XIII), (a)(10)(A)(ii)(XIX), (cc), and (r)(2) and 42 U.S.C. 1396o."
Section 3. Section 53-6-195, MCA, is amended to read:
"53-6-195. Medicaid buy-in program for workers or children with disabilities -- purpose --
eligibility -- participant costs. (1) If appropriations specific for this purpose are provided by the legislature and
federal approval of the necessary amendments to the state medicaid plan is secured, the department shall
administer a medicaid program that allows individuals with disabilities to participate in the medicaid program if:
(a) they obtain employment that increases their incomes above eligibility limits; or
(b) they are under 19 years of age and meet the requirements of subsection (5).
(2) Participants in the program may be required to pay a portion of the costs for participation. The
purpose of the program is:
(a) to support employment for individuals with disabilities by providing medicaid coverage to
individuals who would otherwise be ineligible for medicaid due to earnings that exceed the medicaid program's
income limits; and
(b) to provide medical, habilitative, and rehabilitative services to children with physical or
developmental disabilities at an early age to prevent or reduce their future need for services.
(2)(3) The medicaid program provided for under this section must be implemented in accordance with
the provisions of 42 U.S.C. 1396a(a)(10)(A)(ii)(XIII), (a)(10)(A)(ii)(XIX), (cc), and (r)(2).
(3)(4) An employed individual is eligible for the program under subsection (1)(a) if the individual:
(a) has a net family income that is less than 250% of the federal poverty level;
(b) would be categorically eligible for medicaid because the individual is disabled as defined under
Title XVI of the Social Security Act, 42 U.S.C. 1382c, except that the person has or has had earnings above the
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level for substantial gainful activity;
(c) has income and resources equal to or below the income and resource limits established by the
department by rule, which may be less stringent than the income and resource limits for supplemental security
income benefits; and
(d) satisfies all other eligibility criteria established by the department by rule.
(5) A child is eligible for the program under subsection (1)(b) if the child:
(a) is considered disabled as defined in 42 U.S.C. 1382c(a)(3)(C); and
(b) has a combined family income of up to the maximum level allowed under 42 U.S.C.
1396a(cc)(1)(C)(i).
(4)(6) The department may establish:
(a) requirements for the employment status of participants workers participating in the program,
the verification of the worker's employment status, and permissible temporary breaks in employment;
(b) requirements, limitations, and definitions pertaining to the income and resources of participants;
(c) only to the extent allowed under 42 U.S.C. 1396o and in accordance with subsection (7),
requirements for payment of premiums, deductions, and cost sharing as a condition for participating in the
program. ; and
(d) only to the extent required under 42 U.S.C. 1396(a)(cc)(2)(A):
(i) a requirement for a parent of a child eligible for the program under subsection (1)(b) to enroll in
and pay premiums for family health insurance coverage if the parent's employer offers the coverage; and
(ii) a reduction to the premium imposed by the state by an amount that reflects the parent's
premium contribution for private health insurance for a child with a disability.
(7) A parent of a child eligible for the medicaid buy-in program shall pay premiums. The family's
premiums and cost sharing may not exceed:
(a) 5% of family income for families with an income at or below 200% of the federal poverty level;
or
(b) 7.5% of family income for families with an income above 200% of the federal poverty level.
(5)(8) The department shall, to the extent allowed by appropriations levels and under applicable state
and federal law, coordinate the medicaid program provided for under this section with other state and federal
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programs and resources that promote opportunities for persons with disabilities to retain, regain, and maintain
employment."
Section 4. Appropriation. The following amounts are appropriated to the department of public health
and human services for the biennium beginning July 1, 2025, for the medicaid buy-in program for children with
disabilities:
Fiscal year 2026 $1,835,310 federal special revenue fund
$966,690 general fund
Fiscal year 2027 $1,870,221 federal special revenue fund
$983,336 general fund
Section 5. Effective date. [This act] is effective July 1, 2025.
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I hereby certify that the within bill,
HB 881, originated in the House.
___________________________________________
Chief Clerk of the House
___________________________________________
Speaker of the House
Signed this _______________________________day
of____________________________________, 2025.
___________________________________________
President of the Senate
Signed this _______________________________day
of____________________________________, 2025.
HOUSE BILL NO. 881
INTRODUCED BY M. CAFERRO
AN ACT REVISING THE MEDICAID BUY-IN PROGRAM TO INCLUDE CHILDREN WITH DISABILITIES;
PROVIDING AN APPROPRIATION; EXTENDING RULEMAKING AUTHORITY; AMENDING SECTIONS 53-6-
113, 53-6-131, AND 53-6-195, MCA; AND PROVIDING AN EFFECTIVE DATE.