Montana Medicaid HCBS Waivers: The Big Sky Waiver

Montana Medicaid pays for care in your own home and community, not only in a nursing home, and it does so mainly through one program: the Big Sky Waiver (BSW). Montana Medicaid home- and community-based services (HCBS) waivers like the Big Sky Waiver exist for one reason, which is to let a person who would otherwise need a nursing facility stay in their own home instead.1 To use the Big Sky Waiver, a person has to qualify for Medicaid financially and meet the level of care Montana would require for a nursing-facility placement.

In This Guide

• What Are Montana Medicaid HCBS Waivers?
• Inside the Big Sky Waiver, Montana's HCBS Program
• Who Qualifies for Montana Medicaid HCBS Waivers?
• What the Big Sky Waiver Covers
• Can the Big Sky Waiver Pay a Family Caregiver?
• The Big Sky Waiver Waiting List and How Enrollment Works
• How to Apply for the Big Sky Waiver

What Are Montana Medicaid HCBS Waivers?

Home- and community-based services, usually shortened to HCBS, is the part of Medicaid that pays for long-term care delivered outside an institution, in your own home, a family member's home, or another community setting rather than a nursing facility. States deliver these services under a federal authority called a Section 1915(c) waiver, which lets a state "waive" the usual rule that Medicaid long-term care happens in an institution and instead fund care in the community.1

The idea is straightforward once you see it. Nursing-home care and home care serve the same person with the same level of medical need, but one keeps that person at home. A 1915(c) waiver is the mechanism that lets Medicaid pay for the home option.

Montana runs its main HCBS program for older adults and people with physical disabilities through a single 1915(c) waiver, the Big Sky Waiver. So when families search for Montana Medicaid HCBS waivers, the Big Sky Waiver is almost always the program they are looking for.

Inside the Big Sky Waiver, Montana's HCBS Program

The Big Sky Waiver (BSW) is administered by the Senior and Long-Term Care Division of the Montana Department of Public Health and Human Services (DPHHS). Its purpose is direct: it allows people who would otherwise be institutionalized to live in their own home and community instead.1

Once someone is enrolled, their care is not left to chance. Each participant works with a Case Management Team made up of a nurse and a social worker, who assess needs, build the plan of services, and coordinate the supports that keep the person safely at home.1 That pairing matters, because home-based long-term care usually involves both a medical side and a daily-living side, and the two-person team is set up to cover both.

The waiver's current federal authority (waiver number 0148.R07.00) was approved by the federal Centers for Medicare & Medicaid Services on June 20, 2024, effective July 1, 2024 through June 30, 2029.1 That approval period is worth knowing only because it tells you the program is active and federally authorized through the end of the decade.

Who Qualifies for Montana Medicaid HCBS Waivers?

The Big Sky Waiver serves people ages 65 or older and people ages 0 to 64 with physical or other disabilities who meet a nursing facility level of care.1 Eligibility for the Big Sky Waiver comes down to two tests that a person has to meet at the same time.

The first is functional, meaning it is about your care needs. To qualify, you must meet the minimum level of care required for a nursing-facility placement.1 In plain terms, your needs have to be serious enough that, without help, a nursing facility would be on the table. On top of that, Montana looks for an unmet need that only the Big Sky Waiver's services can resolve, so the waiver is filling a real gap rather than duplicating care you already have.1

The second test is financial. A person must be financially eligible for Medicaid to enroll in the waiver.1 Montana's long-term care Medicaid income and asset rules are their own detailed subject, and you can work through them in our guide to Montana Medicaid income and asset limits. The key point here is that meeting the care level alone is not enough; the financial side has to line up too, and the county office that handles Medicaid eligibility is the one that makes that determination.

What the Big Sky Waiver Covers

The Big Sky Waiver funds a range of home- and community-based supports, not a single service. The exact plan is built around what a participant actually needs, but the services the waiver may include are:1

• Personal assistance with everyday activities
• Homemaker services
• Adult day health
• Respite care, which gives a family caregiver a break
• Environmental adaptations, meaning home modifications such as ramps or grab bars
• A personal emergency response system (PERS), the button or device that summons help in an emergency
• Private duty nursing
• Transportation

Two things are worth underlining. First, this is a "may include" list, so which services a given person receives depends on their assessment and plan, not on the menu being handed out in full.1 Second, several of these supports exist as much for the family as for the participant. Respite care in particular is built to relieve an unpaid family caregiver, which is often the difference between a home arrangement lasting and falling apart.

If the level of care eventually points toward a facility instead, our guide to Montana Medicaid and nursing home care covers that side of long-term care.

Can the Big Sky Waiver Pay a Family Caregiver?

Yes, in some cases. Montana's Big Sky Waiver members can get some types of in-home care from a relative or from a legally responsible individual (LRI), and the program can pay that family member.2 An LRI includes a spouse of an adult member and a court-appointed guardian. A paid LRI must be employed as a Big Sky Waiver personal care worker by a provider agency, or by the member if the member self-directs their services.2

The rules differ by relationship:

• Adult child or other relative: payable as a relative. A draft Big Sky Waiver amendment DPHHS posted in December 2025, with a proposed effective date of June 1, 2026, says relatives may be reimbursed for personal care or similar services when qualified to provide them.2
• Spouse: payable only for extraordinary care. The member must need care beyond the spouse's usual responsibilities, a qualified professional must find that this care serves the member's best interest, and DPHHS policy says the service must be necessary to avoid institutionalization and not something the family would ordinarily do. The spouse must be an employee of a Medicaid provider, may not provide more than 40 hours in a seven-day period, and the choice of a spouse as caregiver must be documented in the plan of care.2
• Authorized representative: a relative, spouse, or guardian who is also the member's authorized representative may not be paid to provide services.2

A few limits apply to every paid family arrangement. Under the draft amendment, the services authorized follow the recommendations of the plan of care professional, and the family member must use electronic visit verification (EVV) for the hours paid, whether the care is agency-based or self-directed. DPHHS policy also says it is never appropriate to authorize State Plan personal assistance through the Big Sky Waiver just so a legally responsible individual can be paid.2 For every Montana route to family caregiver pay, including Community First Choice and VA programs, see our guide to getting paid as a family caregiver in Montana, and for the state plan personal care side, our guide to Montana Community First Choice family caregiver pay.

The Big Sky Waiver Waiting List and How Enrollment Works

The Big Sky Waiver currently operates a waiting list, and that is the fact families most need to plan around.1 Federal rules let a state that offers home care through a waiver cap how many people it enrolls, which is what produces waiting lists.3 So even when you meet both the care-level test and the financial test, an open slot may not be available the day you apply, and you may spend time on the list before enrollment.

That reality shapes the smart move, which is to start early. Getting your referral in and your Medicaid financial eligibility established puts you in the process rather than at the beginning of it, so that when a slot opens you are ready rather than starting from scratch. Waiting to apply until the need is urgent can cost a family months it did not have to lose.

How to Apply for the Big Sky Waiver

Applying for the Big Sky Waiver runs on two tracks that move in parallel, and it helps to picture them side by side.

Track one: the waiver referral. To get into the Big Sky Waiver itself, a person makes a referral by contacting Mountain Pacific at (800) 219-7035 or (406) 443-4020.1 That referral starts the level-of-care assessment and gets you into the waiver's process, including the waiting list.

Track two: Medicaid financial eligibility. Because you must be financially eligible for Medicaid to use the waiver, your Montana Medicaid eligibility is determined by your county Office of Public Assistance.1 Federal rules require the state to let you apply for Medicaid through more than one door, including online, by phone, by mail, or in person.4 Which of those channels Montana actually runs, and at what addresses, is set by the state, so check DPHHS's own instructions. Our step-by-step guide to applying for Montana Medicaid walks through that side in full.

On the financial application, the state also works under a clock. Federal Medicaid regulations give the agency a maximum of 45 days to decide most applications, and up to 90 days for people who apply for Medicaid on the basis of disability, except in unusual circumstances such as a delay on the applicant's side or an emergency beyond the agency's control.5 The longer window turns on the basis the application was filed under, not on whether a disability determination happens to arise, so an older adult applying on the basis of age is on the 45-day standard. Those are ceilings on the agency, not the typical wait or a promised decision date, but they tell you the outer edge of how long the financial determination should take.

The Senior and Long-Term Care Division of DPHHS is the state agency behind the waiver, and its Big Sky Waiver page is the place to confirm current contact details before you call.

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The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.