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    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceMontana DPHHS Big Sky Bonanza Coverage | OpenPayer
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    DraftMontana Department of Public Health & Human ServicesPolicy N/A

    BSW 708 Services: Big Sky Bonanza Consumer Directed Goods and Services (new number to be assigned)

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    Defines Consumer Directed Goods and Services available to members enrolled in the member-directed Big Sky Bonanza option of the Big Sky Waiver, including coverage criteria and service requirements for purchase of goods, supports, and supplies not provided elsewhere by the waiver or Medicaid State Plan.

    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicyBig Sky Bonanza Consumer Directed Goods and Services (BSW 708)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain Department approval and complete prior authorization showing the item addresses an identified need in the member's person-centered service and support plan.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    member-directedwaiver option
    5qualifying purposes
    appliances & vansexample covered items

    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.

    Coverage Criteria and Limitations

    Coverage criteria (qualifying purposes plus service plan and approval)

    Covered when ALL of the following are met:

    Primary coverage rationale

    • Enumerated purposes: The item or service would: 1) decrease the need for other Medicaid services; 2) promote community inclusion; 3) promote the member's independence; 4) fulfill a medical, social, or functional need based on unique cultural approaches; or 5) increase the member's safety in the home environment or community.

      These are alternative qualifying purposes.

    • Additional required criteria: Goods and services purchased must address an identified need in the member's person-centered service and support plan, meet Department approval, and comply with the prior authorization process and available funding review.

      Operational requirements including plan documentation and Department approval.

    Exclusions / duplication risk: Items or services that are provided by Medicaid, Medicare, the Veteran's Administration, other third-party payers, or goods normally furnished by state educational, vocational, or recreational support agencies, or that would be duplicative of covered services, are excluded from coverage.

    Refer to duplication risk and exclusions.

    Items or services that are already provided by Medicaid, Medicare, the Veteran's Administration, other third-party payers, or by state educational, vocational, or recreational support agencies are excluded from coverage. In addition, goods or services that are duplicative of covered services under any of these programs are not eligible for payment through the Big Sky Bonanza Consumer Directed Goods and Services benefit.

    Requests will be denied or considered not allowable when the item or service duplicates coverage available through another payer or is normally furnished by another public program or agency. Items that do not address an identified need in the member’s person-centered service and support plan or that fail to meet Department approval and the prior authorization and funding-review process are also ineligible.

    Provider Responsibilities and Authorization

    Prior Authorization

    Department approval / prior authorization required

    Department approval is required before purchases are made; items are subject to the Department's prior authorization process and review of available funds.

    Step Therapy

    Step therapy: not specified

    No step-therapy or sequential trial requirements are specified in the policy.

    Documentation Required

    Plan documentation and Department approval required

    Goods and services purchased must address an identified need in the member's person‑centered service and support plan and meet the policy's specified coverage requirements.

    • Purchase must address an identified need in the member's person‑centered service and support plan.
    • Purchase must meet one or more qualifying purposes (decrease need for other Medicaid services; promote community inclusion; promote member independence; fulfill a medical, social, or functional need based on unique cultural approaches; or increase safety).
    • Purchases must also comply with Department approval and the prior authorization and available funds review process.
    Denial Risk

    Duplication of coverage may render item ineligible

    Items that duplicate services or supports already provided by Medicaid, Medicare, the Veteran's Administration, other third‑party payers, or by state educational, vocational, or recreational agencies may be ineligible and are subject to review.

    • Goods normally furnished by state educational, vocational, or recreational support agencies are excluded.
    • Items provided by other payers (Medicaid, Medicare, VA, other third parties) that duplicate existing coverage are not allowed.

    Definitions

    Consumer Directed Goods and Services — definition and key requirements
    DefinitionServices, supports, supplies, or goods not otherwise provided through the Big Sky Waiver or the Medicaid State Plan, available to members in the member-directed Big Sky Bonanza option.
    Eligible purposes (any one qualifies)Item/service would: 1) decrease the need for other Medicaid services; 2) promote community inclusion; 3) promote the member's independence; 4) fulfill a medical, social, or functional need based on unique cultural approaches; or 5) increase the member's safety in the home environment or community.
    Service requirement — plan alignmentGoods and services purchased must address an identified need in the member's person-centered service and support plan.
    Department approval and funding reviewPurchases require Department approval and are subject to the prior authorization process and review of available funds.
    Coverage exclusions (duplication risk)Items or services provided by Medicaid, Medicare, the Veteran's Administration, other third-party payers, or normally furnished by state educational, vocational, or recreational agencies, or that duplicate covered services, may be ineligible.
    Example covered itemsMay include purchase of appliances and vans, with or without modifications, when criteria and Department approval are met.

    Background

    The intent of Consumer Directed Goods and Services is to provide members in the member-directed Big Sky Bonanza option with services, supports, supplies, or goods that are not otherwise provided through the Big Sky Waiver or the Medicaid State Plan. These purchases are intended to meet medical, social, or functional needs and to support independence, community inclusion, and safety in the home or community when those needs are not met by other waiver or Medicaid benefits.

    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicyBig Sky Bonanza Consumer Directed Goods and Services (BSW 708)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain Department approval and complete prior authorization showing the item addresses an identified need in the member's person-centered service and support plan.
    SourceLink
    On This Page
    Coverage Criteria and LimitationsProvider Responsibilities and AuthorizationDefinitionsBackground