BSW 728 Services: Residential Habilitation
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, service components, provider requirements, limitations, prior authorization, and retainer day rules for Residential Habilitation services under Montana's Big Sky Waiver for assisted living, specialized assisted living, group homes, adult and youth foster care.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exclusions
Coverage criteria and exclusions
Covered with conditions. The Big Sky Waiver reimburses Residential Habilitation services only when program requirements and exclusions below are met.
Explicit exclusions
- Medicaid reimbursement for room and board is prohibited.
- Waiver funds are not available to pay for maintenance (including room and board) and supervision of children under state custody.
- Members in residential habilitation settings may not receive Personal Assistance (except social PCA/STA beyond facility-required services).
- Members in residential habilitation settings may not receive Homemaking when HCBS Big Sky Waiver payment is being made for residential habilitation.
- Members in residential habilitation settings may not receive Environmental modifications when HCBS Big Sky Waiver payment is being made for residential habilitation.
- Members in residential habilitation settings may not receive Respite when HCBS Big Sky Waiver payment is being made for residential habilitation (respite may be provided to other service types but not on behalf of a residential habilitation setting).
- Members in residential habilitation settings may not receive Meals when HCBS Big Sky Waiver payment is being made for residential habilitation.
- Members in residential habilitation settings may not receive Non-Medical Transportation when HCBS Big Sky Waiver payment is being made for residential habilitation.
Billing during absence and transfer rules
- Provider may not bill Medicaid for services on days the member is absent from the facility unless retainer days (maximum 30 days per service plan year) have been approved by the Case Management Team (CMT).
- Provider may bill on the date of admission to and discharge from a hospital or nursing facility.
- If a member transfers between adult residential care settings, both facilities may not bill on the day of transfer; the admitting facility bills for that day.
PERS and bundled service guidance
- Personal Emergency Response Systems (PERS) are a required component of an assisted living facility and should not be routinely reimbursed by waiver funds; the Case Management Team may authorize PERS only when specific reasons are documented prior to initiation of service.
- Residential habilitation is a bundled service that includes multiple services; the listed restrictions on other services apply only when HCBS Big Sky Waiver payment is being made for the residential habilitation service.
Member choice and notice
- If a Big Sky Waiver member leaves a residential habilitation care setting without giving the contractually required 30-day notice to the facility, HCBS Big Sky Waiver reimbursement cannot be used to pay the daily rate for the remaining days.
Billing, Codes, and Retainer Limits
| No codes listed |
Prior Authorization and Provider Requirements
Prior authorization required for assisted living behavior management & CC3
Assisted living facility behavior management services and Specialized Assisted Living (CC3) must be prior authorized by the Department in collaboration with the requesting assisted living provider; approval may also result in establishment of a care category 3 (CC3).
- Behavior management is provided to residents who have resided in a licensed assisted living facility over 30 days.
- Specialized assisted living is a CC3 bundled service and must be initially prior authorized by the Department.
Initial prior authorization required for group homes
Group home services and Specialized Adult Residential requirements must be initially prior authorized by the Department before services are provided.
- Group homes and Specialized Adult Residential care facilities must be licensed by the State of Montana.
- Group home services are bundled CC3-type services and include 24-hour on-site staff and targeted service delivery.
Case Management authorization required for retainer days; 30-day limit
Retainer days require authorization by the Case Management Team and payment for retainer days may not exceed 30 days per service plan year.
- Retainers apply when the member is in the hospital, nursing facility, or on vacation and the team authorizes reimbursement to preserve the member's placement.
- If a provider rate includes vacancy savings, retainer days may not be paid in addition (duplicate payments prohibited).
Key Definitions
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.