Montana Big Sky Waiver: Montana 2026 Guide

The Big Sky Waiver (BSW) is Montana Medicaid’s main program for paying for long-term care outside a nursing home. It serves older adults and adults with physical disabilities who need the level of care a nursing facility provides but would rather receive help at home, in an adult foster home or in assisted living. It is run by the Senior and Long-Term Care Division of the Montana Department of Public Health and Human Services (DPHHS).

Here is a plain-language walk-through of the Big Sky Waiver: who qualifies in 2026, what help it covers, how a family gets started, whether there is a wait, and how it connects to nursing home coverage. For the full statewide rules on income, assets, spouses and the look-back, see our Montana Medicaid guide.

Figures change periodically. Double-check current amounts before relying on them.

What the Big Sky Waiver is

The Big Sky Waiver is a 1915(c) waiver. Each participant works with a case management team, usually a registered nurse and a social worker, who visit the person, assess needs and write a plan of care. Services are then arranged through approved providers in the person’s area. Participants can receive services in their own home, in an adult foster home, or in a licensed assisted living facility, and some services can be self-directed, which means the participant (or a representative) hires and supervises their own workers.

A home and community-based services (HCBS) waiver is a Medicaid program a state runs with federal approval. “Waiver” means the state may set aside some normal Medicaid rules, such as the rule that long-term care is paid only in a nursing home, so it can pay for care at home or in a community setting instead. Since no state has to offer a waiver, each program’s services and size are set by the state and its federal agreement. Being eligible, in other words, is not the same as being enrolled.

Who qualifies in 2026

Eligibility for the Big Sky Waiver rests on two tests, care need and finances, plus an available slot. In general, an applicant must:

• be 65 or older, or be an adult with a physical disability as determined under Social Security rules;
• live in Montana;
• meet a nursing facility level of care, based on a screening by the state’s level-of-care contractor;
• have a need that Big Sky Waiver services can meet, which the case management team confirms;
• be financially eligible for Montana Medicaid; and
• be offered an opening, since the waiver has a limited number of slots.

Income and assets. The financial side of the Big Sky Waiver follows Montana’s long-term care Medicaid rules. Bank and investment accounts count toward the limit, but a home, one vehicle, household goods and limited burial funds generally do not. Gifts made in the five years before applying can trigger a penalty that delays waiver services, just as it would delay nursing home coverage.

Montana does not use a fixed income cap for nursing home Medicaid, but waiver applicants whose income is above the regular Medicaid limit may need to meet a monthly spend-down (called an incurred medical expense) before Medicaid pays. The single-person asset limit is $2,000.

Montana’s 2026 long-term care Medicaid numbers, from our state guide:

Couples. Spousal impoverishment rules generally apply to waiver applicants in Montana, protecting a share of assets and income for the spouse at home. The spousal allowance pages explain how these amounts are figured.

Services the Big Sky Waiver can cover

Services are listed in a written plan of care, built from the assessment and the person’s goals. Not everyone gets every service. Depending on need, the Big Sky Waiver can include:

• case management by a nurse and social worker team
• personal assistance and specially trained attendant care
• homemaker and chore services
• adult day health
• respite care for family caregivers
• adult residential care, including assisted living and adult foster homes
• private duty and skilled nursing, and some therapies
• personal emergency response systems
• environmental changes to the home and vehicle changes
• specialized medical equipment and supplies
• meals and nutrition services
• self-directed personal assistance, where the participant hires the worker

Limits to keep in mind. the Big Sky Waiver does not pay for rent, groceries or utilities; in residential settings, room and board is the resident’s responsibility. The plan of care often assumes some help from relatives where it is available. Medical care continues through Medicaid and Medicare in the usual way.

How to apply for the Big Sky Waiver

The usual sequence for the Big Sky Waiver is below. Running the financial application and the care assessment in parallel can shorten the wait.

1. Apply for Montana Medicaid online through the state’s benefits website or through the county Office of Public Assistance, if you are not already on Medicaid.
2. Request a Big Sky Waiver referral. The state’s level-of-care contractor screens whether the person meets nursing facility level of care.
3. If the person qualifies and no slot is open, they are placed on the waiting list and scored for priority.
4. When a slot opens, a case management team in your region contacts you, completes a full assessment and writes the plan of care.
5. Choose providers, or set up self-direction, and services start under the plan.

Practical tips. Keep copies of everything you send and note the name of each person you speak with. At the assessment, talk about the hardest days, not the best ones, and bring someone who sees the care needs firsthand. Supervision needs, confusion and falls matter as much as hands-on help. A denial notice explains the fair hearing process and its deadline.

Waiting lists and timing

The Big Sky Waiver has a waiting list. It is not an entitlement, and openings go first to people with the greatest need, based on a statewide scoring tool rather than strictly first come, first served. People who are moving out of a nursing home or are at high risk of entering one may score higher. Waiting times vary by region and over time.

Starting the process early keeps options open if a wait develops. Stopgaps can include state plan home care, adult day centers, PACE where it operates and local aging services. The waiver waiting lists page explains common rules.

How it relates to nursing home Medicaid

Because participants meet a nursing home level of care, the Big Sky Waiver is a substitute for nursing home care, not a step below it. One practical difference: nursing home Medicaid has no enrollment cap in Montana, while a waiver can. If care at home becomes unsafe, a participant can move to a nursing home and keep Medicaid, though the share of income paid toward care changes. Moving the other way is often given priority, and Money Follows the Person can help.

Tips for families

Begin before the situation is urgent; every step takes longer than families expect. Gather five years of bank statements before the caseworker requests them, and keep a two-week care diary before the assessment. Higher income may call for a Miller trust or spend-down; past gifts may cause a penalty, so review them first. A reassessment can be requested whenever needs change.

Many families find it worthwhile to talk with a Certified Medicaid Planner before applying for the Big Sky Waiver. A planner who knows Montana’s rules can review income and assets, explain which program fits, map the timing against any waiting list, and help with the paperwork. Fees vary: roughly $500 to $6,000 for application help, $2,500 to $15,000 or more for full planning, and $150 to $600 an hour for advice.

Related pages

• Montana Medicaid guide
• Montana CFCS and PCS
• HCBS waivers explained
• Applying for a waiver
• Nursing home level of care
• Waiver waiting lists
• The five-year look-back

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.