Basic Medicaid 1115 Waiver
State Medicaid programs may request from the Centers for Medicare and Medicaid Services (CMS) a waiver(s) of certain federal Medicaid requirements that are found in the Social Security Act. A common public misconception is that any portion of the Medicaid program can be waived by CMS. In reality, only certain requirements can be waived. The Basic Medicaid Waiver renewal extension was approved by CMS and effective December 1, 2010 through December 31, 2013. CMS has approved the Basic Waiver to offer a smaller package of Medicaid benefits called Basic Medicaid. This waiver also allows Montana to offer Basic benefits only to Able Bodied Adults and up to 800 qualified individuals with schizophrenia or bipolar disorder.
Two populations are currently covered under the Basic Medicaid Waiver:
1) Since 1996 the Basic Medicaid Waiver has covered Able Bodied Adults age 21 to 64 (neither pregnant nor disabled), who are parents and/or caretaker relatives of dependent children, who are qualified under Section 1925 and 1931 of the Social Security Act, with incomes at or below 33% of the Federal Poverty Level (FPL) (must meet monthly Medicaid reporting criteria); and
2) Effective December 1, 2010 the Basic Medicaid Waiver can cover up to 800 individuals who have a primary clinical diagnosis of a severe disabling mental illness (SDMI) of schizophrenia or bipolar disorder, who are qualified for the State only Mental Health Services Plan (MHSP) Program, aged 18 through 64, with incomes at or below 150% FPL, who are residents of Montana, and who are not otherwise eligible for Medicaid.
Waiver enrolled individuals with schizophrenia or bipolar disorder receive Basic benefits for 12 months of continuous eligibility without reporting monthly changes of income or resources. Individuals will not be eligible if they are no longer Montana residents or become otherwise eligible for Medicaid. Individuals will remain enrolled if, at the time of redetermination every 12 months, they meet the same eligibility qualifications.
Is this also called HIFA (Health Insurance Flexibility and Accountability Waiver) or MHSP Waiver?
Prior to the addition of the individuals with schizophrenia or bipolar disorder into the Basic Medicaid Waiver in December 2010, the concept of adding the new population was sometimes called HIFA and even informally called the MHSP Waiver. Formally, the two populations (Able Bodied Adults and qualified individuals with schizophrenia and bipolar disorder) make up the individuals approved for Basic Medicaid benefits in the Basic Medicaid Waiver.
Basic Medicaid Benefit
The Basic package is the Full Medicaid benefit, with the following medical services generally excluded under Basic Medicaid: audiology, dental and denturist, durable medical equipment, eyeglasses, optometry and ophthalmology for routine eye exams, personal care services, home infusion and hearing aids.
Basic Medicaid Allowances/Special Circumstances
DPHHS recognizes there may be situations where the excluded services are necessary as in an emergency or when essential for employment. Coverage for the excluded services may be provided at the State’s discretion in cases of emergency or when essential to obtain or maintain employment.
Examples of emergency circumstances include, but are not limited to, coverage for emergency dental situations, medical conditions of the eye, which include but are not limited to annual dilated eye exams for individuals with diabetes or other medical conditions, and certain medical supplies such as diabetic supplies, prosthetic devices and oxygen. In these situations, the State will provide approval to the provider, and make associated records available upon CMS request.
Medicaid Client Handbook – Benefit Coverage
The Medicaid Client Handbook is a great place to see the general coverage for Basic Medicaid. The chart of benefits in the handbook starts on page 16 showing both Full and Basic benefits. In general and if medically necessary, benefits like doctor, clinic, inpatient/outpatient hospital, prescription drugs, family planning, home health services, hospice, nursing home, lab, mental health services, OB, OT, PT, ST, social worker, substance dependency non hospital outpatient, surgery, and non emergency transportation (to list a few examples), are covered for both Full and Basic Medicaid. See the Medicaid Client Handbook at:
Please direct any questions regarding Able Bodied Adult Medicaid eligibility to your local County Office of Public Assistance. Please direct any eligibility or benefit questions regarding individuals with schizophrenia or bipolar disorder to:
Marcia Armstrong, 444-2878
DPHHS, Addictive and Mental Disorders Division
PO Box 202905
Helena, Montana 59620-2905
(406) 444-2878 or at email@example.com
Please direct any questions or comments about the Basic Medicaid Waiver to:
DPHHS, Director’s Office
PO Box 4210
Helena, Montana 59604
(406) 444-4146 or at firstname.lastname@example.org