ACA Adult Medicaid and ACA Adult
Customize your policy alerts
Sign up for all Montana Department of Public Health & Human Services policy alerts
Know when Montana Department of Public Health & Human Services releases new policies or updates existing guidance.
Monitor payer policy activity
Defines eligibility, financial and non-financial criteria, filing unit rules, and termination reasons for Montana's ACA Adult and ACA Adult Medicaid coverage groups for adults aged 19–64.
No material clinical or coverage changes in this revision.
Eligibility and Coverage Criteria
ACA Adult / ACA Adult Medicaid eligibility
Eligibility requires meeting all of the following financial and non‑financial criteria.
ALL of the following
Financial criteria
- Income determined under MAGI rules and compared to the Federal Poverty Level (FPL).MAGI vs FPL
Apply 5% disregard to total countable income before comparing to FPL.
Income limits
- ACA Adult Medicaid: MAGI after 5% disregard is 0%–50% of FPL.
- ACA Adult: MAGI after 5% disregard is 51%–133% of FPL.
Non‑financial criteria
- Age 19 through 64 years.
- Not eligible for or enrolled in Medicare Parts A and/or B.
- Not pregnant at application.
- Meet Community Engagement requirements during the look‑back period, have a temporary exemption, or qualify for an exclusion (see CMA 310‑1).
- Meet standard Medicaid non‑financial requirements per CMA 300 NonFinancial Overview.
Income Thresholds and Coding
| No codes listed |
Filing Unit and Coverage Closure Actions
Filing unit determination (use ACA tax filing rules)
Determine required filing unit members using ACA tax filing rules by applying the guidance in FMA 200-1 (ACA Filing Unit).
- Use tax filing rules to identify who must be included in the filing unit.
- Follow FMA 200-1 for the specific ACA filing unit requirements and any exceptions.
Coverage closure — complete ex parte review
When coverage is closing because of a reported or discovered change, complete an ex parte review in accordance with CMA 1501-1 (Reporting Changes).
- Perform an ex parte review whenever closure is due to a reported or discovered change.
- Reference CMA 1501-1 for procedures and documentation requirements for reporting changes and ex parte actions.
Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.