Montana - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Montana Department of Public Health and Human Services (DPHHS) Office of Inspector General (OIG) Licensure Bureau licenses Assisted Living Facilities under Administrative Rules of Montana (ARM) Title 37, Chapter 106, Subchapter 28. Medicaid reimbursement for these services is primarily funded through the Big Sky Waiver administered by the Senior and Long Term Care Division, and the Severe and Disabling Mental Illness (SDMI) HCBS Waiver administered by the Behavioral Health and Developmental Disabilities Division.

Applicants must secure local building code approval and a Certificate of Occupancy before submitting the licensure application, and must submit comprehensive policies and procedures to the Licensure Bureau at least 45 days prior to the expected opening date. Montana does not require a Certificate of Need for this service, allowing providers to apply directly for licensure and subsequent Medicaid enrollment through the Provider Services Portal once physical plant approvals are secured.

1. Service Definition and Scope

In Montana, an Assisted Living Facility (ALF) is defined as a congregate residential setting that provides or coordinates personal care, health-related services, scheduled and unscheduled 24-hour supervision and assistance, and activities. Facilities are licensed by categories based on the acuity and needs of the residents they serve.

Medicaid waiver programs utilize these licensed facilities to provide Adult Residential Living services, ensuring individuals who would otherwise require nursing facility placement can remain in a community-based setting.

• Category A: Residents who do not require skilled nursing care, can self-evacuate, and need assistance with standard activities of daily living.
• Category B: Residents who require skilled nursing care or assistance with ADLs beyond Category A, requiring the facility to have specialized endorsements and nursing staff.
• Category C: Residents with severe cognitive impairment, such as Alzheimer's or dementia, requiring a secured environment and specialized programming.
• Category D: Residents with mental health needs, often aligned with the SDMI waiver population.
• Big Sky Waiver: Funds Adult Residential Living services for elderly individuals and adults with physical disabilities.
• SDMI Waiver: Funds assisted living services for adults with severe and disabling mental illness.

2. Regulatory and Oversight Agencies

The Montana Department of Public Health and Human Services (DPHHS) is the primary umbrella agency. Within DPHHS, the Office of Inspector General handles facility licensure, while separate divisions manage the specific Medicaid waivers.

Medicaid enrollment and claims are processed through the state's fiscal agent via the Provider Services Portal.

• DPHHS Office of Inspector General (OIG) Licensure Bureau: Issues facility licenses, reviews policies, and conducts onsite compliance surveys (https://dphhs.mt.gov/oig/Licensure/HealthCareFacilityLicensure).
• DPHHS Senior and Long Term Care Division (SLTC): Administers the Big Sky Waiver for the elderly and physically disabled (https://dphhs.mt.gov/sltc/).
• DPHHS Behavioral Health and Developmental Disabilities Division (BHDD): Administers the SDMI HCBS Waiver (https://dphhs.mt.gov/bhdd/).
• Montana Healthcare Programs Provider Services Portal: The MMIS portal for Medicaid provider enrollment, revalidation, and claims submission (https://portal.mt.healthinteractive.net/icapPortal/).
• Montana State Fire Marshal: Conducts life safety code inspections required for facility licensure (https://dojmt.gov/enforcement/fire-prevention-and-investigation-section/).

3. Gatekeeping Prerequisites: Who Can Even Apply

Montana does not utilize a Certificate of Need (CON) program for Assisted Living Facilities. The primary structural preconditions are related to physical plant readiness and local zoning approvals.

Before the state will accept a licensure application, the physical building must be approved for occupancy by local authorities.

• Certificate of Need (CON): Explicitly not required for Assisted Living Facilities in Montana; applicants do not need Health Planning Program review.
• Certificate of Occupancy: Required from the local or State building code authority prior to submitting the licensure application for new construction.
• Fire Marshal Approval: Required inspection and approval from the State Fire Marshal or local authority having jurisdiction before a license is issued.
• Administrator Qualifications: The prospective administrator must be a licensed nursing home administrator or complete the self-study modules of the Assisted Living University within 6 months of employment.
• Waiver Capacity Limits: While licensure is open, Medicaid waiver contracting depends on the regional Case Management Team (CMT) and available slots within the Big Sky or SDMI waivers.

4. Licensure and Certification Requirements

The licensure process is managed by the DPHHS OIG Licensure Bureau. Facilities must submit detailed physical plant documentation and operational policies before an onsite inspection is scheduled.

New facilities are initially granted a provisional license, allowing them to admit residents and begin operations while awaiting a full survey.

• Application Form: Providers must submit the DPHHS OIG Assisted Living Facility License Application along with the required fee.
• Floor Plan Submission: Must document the size of all rooms and spaces utilized by residents, excluding door-swing areas and built-in obstructions from square footage calculations.
• Policy Review Window: Comprehensive policies and procedures must be submitted to the Licensure Bureau at least 45 days prior to the expected facility opening date.
• Physical Compliance Inspection: An onsite review by the Bureau Construction Consultant is required prior to the issuance of any license.
• Provisional License: Upon approval of documents and the construction inspection, the state issues a 6-month provisional license.
• Initial Survey: A health care facility surveyor conducts a full onsite survey within the 6-month provisional period to grant a standard 1-3 year license.

5. Medicaid Provider Enrollment

Once licensed, facilities wishing to serve Medicaid waiver participants must enroll through the Montana Healthcare Programs Provider Services Portal.

Enrollment requires coordination with the regional Case Management Team (CMT), which authorizes the specific procedure codes and rates for the facility.

• Provider Type: Assisted Living Facilities must enroll using HCBS Provider Type 28.
• Enrollment Portal: Applications are submitted electronically through the Provider Services Portal managed by the state's fiscal agent.
• CMT Coordination: The regional Case Management Team informs the state of the provider's qualifications, prompting the department to authorize procedure codes and rates.
• Provider Charge File: The state establishes a charge file in the MMIS listing the specific procedure codes, rates, and effective dates the provider is authorized to bill.
• Revalidation: Providers must revalidate their Medicaid enrollment every 5 years in accordance with ACA requirements.

6. Staffing, Training and Background Checks

Staffing requirements are dictated by ARM 37.106.2814 and vary based on the facility's licensure category (A, B, C, or D).

Facilities must maintain sufficient awake staff at all times to meet the scheduled and unscheduled needs of all residents.

• Administrator Training: Must complete state-recognized training and submit a statement confirming review of the Montana rules pertaining to assisted living.
• Direct Care Staff Training: Must be trained on facility policies, resident rights, and the Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act.
• Staffing Ratios: Must maintain sufficient staff 24/7 to meet resident care plans; Category B and C endorsements require specialized nursing or dementia-trained staff.
• First Aid and CPR: At least one staff member with current CPR and First Aid certification must be on shift at all times.
• Background Checks: All staff with direct resident access must undergo criminal background checks through the Montana Department of Justice.

7. Documentation, Policies and Records

Facilities must maintain rigorous documentation to comply with OIG Licensure Bureau standards. Category B and C endorsements require additional, specialized policies.

Resident records must clearly delineate the services provided, the costs, and the medical necessity of any nursing tasks.

• Resident Agreements: Must detail the services provided by the facility, room and board charges, and criteria for discharge or transfer.
• Service Plans: Individualized care plans must be developed for each resident and updated annually or upon a significant change in condition.
• Practitioner Orders: Required for any medication administration or delegated nursing tasks, particularly in Category B facilities.
• Disaster Preparedness: Written emergency evacuation plans are required, and exit doors must utilize single-motion locks approved by the state.
• Incident Reporting: Documented policies for reporting abuse, neglect, or severe injuries to DPHHS and the regional CMT.

8. Billing, Rates and Claims

Medicaid waiver funds cover the cost of care services, but federal rules prohibit Medicaid from paying for room and board in an Assisted Living Facility.

Claims are submitted through the MMIS portal, which is scheduled to transition to the new Montana Healthcare Claims System (MTHCS) in 2027.

• Room and Board: Medicaid does not pay room and board; residents pay this from SSI, Optional State Supplement (OSS), or private funds.
• Service Billing: Care services are billed through the Provider Services Portal using authorized HCBS procedure codes linked to the provider's charge file.
• Prior Authorization: All waiver services must be prior-authorized by the resident's Case Management Team (CMT) before claims will pay.
• Personal Needs Allowance: Residents must be allowed to retain a state-mandated personal needs allowance from their monthly income.
• System Transition: Providers must ensure their contact information is updated in the current portal to receive credentials for the MTHCS transition in 2027.

9. Approval Sequence and Timeline

The pathway to becoming a billing provider requires sequential approvals from local building authorities, the state fire marshal, the licensure bureau, and Medicaid enrollment.

Facilities cannot admit residents until the provisional license is issued.

• Step 1: Obtain local zoning approval and a Certificate of Occupancy for the physical building.
• Step 2: Submit the licensure application, fee, and detailed floor plans to the DPHHS OIG Licensure Bureau.
• Step 3: Submit comprehensive policies and procedures at least 45 days prior to the expected opening date.
• Step 4: Pass inspections by the State Fire Marshal and the Bureau Construction Consultant.
• Step 5: Receive a 6-month provisional license and begin admitting residents.
• Step 6: Enroll as a Provider Type 28 in the Provider Services Portal and coordinate with the CMT for rate authorization.
• Step 7: Pass the initial onsite health care facility survey to receive a full 1-3 year operating license.

10. Common Denials and Survey Findings

The OIG Licensure Bureau frequently cites facilities for physical plant issues and documentation lapses during the initial provisional period.

Failure to adhere to the specific requirements of Category B or C endorsements is a common source of survey deficiencies.

• Physical Plant Deficiencies: Incorrect room measurements or failure to install approved single-motion locks on exit doors.
• Incomplete Policies: Failure to submit comprehensive, category-specific policies 45 days prior to opening, delaying the provisional license.
• Medication Errors: Unlicensed staff performing delegated nursing tasks without proper training or documented practitioner orders.
• Service Plan Lapses: Failure to update resident service plans following a significant change in condition or hospital discharge.
• Background Check Gaps: Allowing staff to work direct-care shifts before background clearances are fully returned and reviewed.

11. Key Contacts and Resources

Providers must interact with multiple DPHHS divisions and portals to maintain compliance and billing capabilities.

The Administrative Rules of Montana (ARM) serve as the definitive legal standard for facility operations.

• DPHHS OIG Licensure Bureau: https://dphhs.mt.gov/oig/Licensure/HealthCareFacilityLicensure
• Montana Healthcare Programs Provider Portal: https://portal.mt.healthinteractive.net/icapPortal/
• DPHHS Senior and Long Term Care Division (Big Sky Waiver): https://dphhs.mt.gov/sltc/
• DPHHS Behavioral Health and Developmental Disabilities Division (SDMI Waiver): https://dphhs.mt.gov/bhdd/
• Montana State Fire Marshal: https://dojmt.gov/enforcement/fire-prevention-and-investigation-section/

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