Montana Medicaid Waiver Assisted Living: Big Sky Waiver Coverage for ALFs
What the Big Sky Waiver Covers in Assisted Living
Montana's Big Sky Waiver — a 1915(c) Home and Community-Based Services waiver — funds personal care and health-related services in licensed assisted living facilities. It does not cover room and board. That distinction is critical: the waiver pays for the care component, but the resident or their family must pay the housing and meal costs separately, typically from the person's Social Security or pension income.
The waiver also covers services beyond assisted living: personal care at home, adult day care, respite care, home modifications, and environmental accessibility adaptations. For families choosing assisted living over nursing home placement, the waiver makes the care affordable while the resident covers basic living costs.
Montana's Three Assisted Living Categories
Under ARM 37.40.1435 and MCA 50-5-226, Montana licenses assisted living facilities in three categories. The category determines the level of care the facility can provide and the waiver reimbursement rate it receives.
Category A facilities serve residents who need 24-hour supervision but not continuous skilled nursing. The resident must be able to handle basic activities of daily living with supervision or minimal help and cannot be totally dependent in four or more ADLs. They need enough cognitive capacity to express needs and make basic care decisions.
Category B facilities can provide skilled nursing care for more than 30 days per incident, up to 120 days per year. Residents may be dependent in more than four ADLs. A licensed professional must complete and sign a healthcare assessment every quarter.
Category C facilities serve residents with severe cognitive impairment — advanced Alzheimer's or other dementia — who cannot express needs or make basic care decisions. These facilities provide secured environments for residents at risk of leaving without regard for personal safety. This is Montana's memory care tier.
The waiver reimburses at different rates for each category, with Category C receiving the highest reimbursement to reflect the intensity of care required.
Eligibility for Waiver-Funded Assisted Living
Three requirements must be met:
Medicaid financial eligibility. Countable assets at or below $2,000 for a single applicant. For Big Sky Waiver eligibility, the research lists a $994/month income limit (100% of the Federal Benefit Rate); do not assume that the nursing-home medically needy spend-down rules apply to the waiver without confirming the applicable pathway with DPHHS.
Nursing facility level of care. Mountain Pacific Quality Health (MPQH) must certify that the person requires the level of care a nursing home provides. This clinical screening evaluates functional capabilities across multiple domains — orientation, memory, ambulation, medication management, and behavioral appropriateness — scoring each on a 0-to-3 scale.
An unmet care need. The waiver serves people whose care needs cannot be met by existing informal supports alone.
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The Waiting List Reality
The Big Sky Waiver operates under capped enrollment. Unlike the Community First Choice program (which has no enrollment cap), waiver slots are limited by the state's agreement with CMS. The research reports an average of 354 people on the waiting list in SFY 2024.
Openings are not assigned first-come, first-served. DPHHS uses a priority scoring system — the Wait List Criteria Tool (Form SLTC-146) — that ranks applicants by the urgency and complexity of their care needs. Someone at risk of imminent institutional placement scores higher than someone with stable informal caregiving.
Some families navigate this by having their parent enter a nursing home temporarily on Medicaid, then seeking assisted living once a waiver slot opens. Families should confirm with DPHHS how an existing Medicaid case and the waiver application coordinate.
How Room and Board Costs Work
When a waiver participant lives in an assisted living facility, their monthly costs split into two buckets:
The care component — personal assistance, medication management, health monitoring — is covered by the waiver.
The room and board component — the actual housing, meals, and facility amenities — is the resident's responsibility. The resident typically pays this from their monthly income (Social Security, pension), retaining only the $50 personal needs allowance that Medicaid preserves.
If the resident has a spouse at home, spousal impoverishment protections apply. The community spouse keeps their own income plus any transfer needed to reach the $2,705.00 monthly maintenance needs floor, with the applicant's remaining income going toward room and board.
Applying for the Waiver
Start with a Medicaid application through apply.mt.gov, by calling 1-888-706-1535, or at your regional Office of Public Assistance. Financial eligibility is determined first.
Simultaneously, request a level-of-care screening through MPQH at 1-800-219-7035. The clinical and financial tracks can run in parallel.
If both are approved and a waiver slot is available, a case manager develops an individualized service plan. If no slot is available, the applicant goes on the priority-scored waiting list.
For a step-by-step guide through the waiver application process, eligibility worksheets, and strategies for navigating the waiting list, see the Montana Medicaid Long-Term Care & Asset Protection Guide.
Get Your Free Montana — Medicaid Long-Term Care Eligibility Checklist
Download the Montana — Medicaid Long-Term Care Eligibility Checklist — a printable guide with checklists, scripts, and action plans you can start using today.