Manatt on Medicaid: CMS Approves Montana Waiver to Expand Medicaid

Authors: Deborah Bachrach, Partner | Patricia Boozang, Senior Managing Director | Kinda Serafi, Counsel

On November 2, 2015, the Centers for Medicare and Medicaid Services (CMS) approved Montana’s request under Section 1115 of the Social Security Act to implement its Medicaid expansion. Referred to as the Health and Economic Livelihood Partnership (HELP) Program, the five-year Demonstration will cover up to an estimated 70,000 new adults. CMS also approved the State’s companion Section 1915(b)(4) Waiver request, allowing Montana to selectively contract with a Third-Party Administrator (TPA) to administer healthcare services to new adults under the Demonstration. Enrollment for the HELP Program began on November 1, 2015, with coverage beginning on January 1, 2016.

Most new adults will receive services through the TPA, and will be subject to co-payments and premiums. Some individuals will be excluded from the TPA, including: the medically frail; individuals who live in a region, including an Indian reservation, where Montana’s TPA is unable to contract with a sufficient provider network; individuals who require continuity of coverage that is not available or could not be effectively delivered through the TPA; and individuals with income below 50 percent of the Federal Poverty Level (FPL).¹ Read more