Montana - Residential Care Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Montana's Department of Public Health and Human Services (DPHHS) Quality Assurance Division (QAD) licenses 24-hour residential settings as either Community Homes for Persons with Developmental Disabilities or Assisted Living Facilities, which are then funded through the 1915(c) Comprehensive Waiver or the Big Sky Waiver. The service, formally billed as Residential Habilitation or Assisted Living depending on the waiver, requires providers to secure a physical facility license under Administrative Rules of Montana (ARM) Title 37 before any Medicaid enrollment application is accepted.

Approval requires passing a QAD life-safety and programmatic inspection, securing a specific Developmental Disabilities Program (DDP) or Senior and Long Term Care (SLTC) provider contract, and submitting a full enrollment application through the Conduent-managed Montana Healthcare Programs portal. Providers must also demonstrate full compliance with the CMS HCBS Settings Rule, ensuring the physical address does not have institutional characteristics and allows for full community integration.

1. Service Definition and Scope

In Montana, Residential Habilitation and Assisted Living waiver services provide 24-hour supervision, skill-building, and personal care in a licensed, provider-owned or controlled setting. These services are designed to support individuals with intellectual and developmental disabilities (IDD), severe and disabling mental illness (SDMI), or physical disabilities in integrated community environments.

The scope of the service includes assistance with activities of daily living (ADLs), medication administration, behavioral support, and community integration, delivered in accordance with the member's Personal Supports Plan (PSP) or care plan.

• Target Populations: Individuals enrolled in the 1915(c) DD Comprehensive Waiver, Big Sky Waiver, or SDMI Waiver.
• Setting Types: Licensed Community Homes for Persons with Developmental Disabilities (group homes) or Assisted Living Facilities (ALFs).
• Included Supports: 24-hour supervision, personal care, habilitation, skill-building, and transportation coordination.
• Excluded Costs: Medicaid HCBS funds cannot be used to pay for room and board; these costs are covered by the resident's SSI or private funds.
• Service Authorization: Services must be explicitly authorized in the individual's care plan by a DDP or SLTC case manager.

2. Regulatory and Oversight Agencies

Oversight of residential HCBS in Montana is divided between the licensing authority and the specific waiver operating agencies within DPHHS. The Quality Assurance Division handles physical plant and safety licensing, while the program divisions manage waiver compliance and contracting.

Medicaid provider enrollment and claims processing are managed by Conduent, the state's fiscal agent for Montana Healthcare Programs.

• Licensing Agency: DPHHS Quality Assurance Division (QAD) (https://dphhs.mt.gov/qad/) issues facility licenses and conducts life-safety surveys.
• Waiver Authority (IDD): DPHHS Developmental Disabilities Program (DDP) (https://dphhs.mt.gov/dsd/developmentaldisabilities/) administers the 1915(c) DD waiver.
• Waiver Authority (Aging/Physical): DPHHS Senior and Long Term Care Division (SLTC) (https://dphhs.mt.gov/sltc/) administers the Big Sky Waiver.
• Fiscal Agent: Conduent (https://medicaidprovider.mt.gov) processes Medicaid provider enrollment applications and manages the MMIS.

3. Gatekeeping Prerequisites: Who Can Even Apply

Montana requires prospective residential providers to clear specific structural prerequisites before Medicaid enrollment is possible. A provider cannot simply enroll as a Medicaid HCBS provider and then look for a building; the physical site must be secured and licensed first.

Additionally, providers must secure a contract with the relevant DPHHS division (DDP or SLTC) to serve waiver members, which may depend on regional network capacity or the provider being selected by a waiver participant.

• Facility Licensure: An active license from DPHHS QAD for the specific physical address (Community Home or ALF) is required before Medicaid enrollment.
• Division Contracting: Providers must obtain a DD Provider Contract or SLTC agreement to deliver waiver services.
• NPI Requirement: Applicants must obtain a Type 2 National Provider Identifier (NPI) and register it on the NPPES registry.
• Business Registration: The operating entity must be registered and in good standing with the Montana Secretary of State.
• HCBS Settings Compliance: The proposed physical address must pass an initial HCBS Settings Rule validation to ensure it is not institutional in nature.

4. Licensure and Certification Requirements

Residential care settings must be licensed by the DPHHS Quality Assurance Division under ARM Title 37. Community Homes for Persons with Developmental Disabilities are governed by ARM 37.100.301 et seq., while Assisted Living Facilities follow ARM 37.106.2801 et seq.

The licensure process involves submitting a detailed application, floor plans, zoning approvals, and passing a rigorous on-site inspection by QAD and the State Fire Marshal.

• Application Form: Submission of the QAD initial licensure application specific to the facility type, along with the required licensing fee.
• Fire Safety: A passed inspection by the State Fire Marshal or local authority having jurisdiction (AHJ) verifying compliance with the NFPA Life Safety Code.
• Zoning Approval: Written documentation from local government confirming the address is zoned appropriately for a residential care facility.
• Policy Manuals: Submission of comprehensive facility policies, including emergency preparedness, medication management, and resident rights.
• Programmatic Review: For DD Community Homes, DDP must review and approve the programmatic aspects of the home before QAD issues the final license.

5. Medicaid Provider Enrollment

Once licensed, the agency must enroll as a Montana Healthcare Programs provider through the Conduent portal. Providers must select the correct enrollment type (e.g., Group or Facility) and use the designated HCBS provider type code (such as Provider Type 28 for certain HCBS waivers).

The enrollment process requires full disclosure of ownership and control interest, as mandated by CMS, and submission of the QAD license and division contract.

• Enrollment Portal: Applications must be submitted via the Montana Healthcare Programs Provider Information website (https://medicaidprovider.mt.gov/providerenrollment).
• Provider Type: Applicants must select the appropriate HCBS provider type and taxonomy code as directed by the specific waiver manual.
• Ownership Disclosure: Full completion of the ownership/control information section per 42 CFR 455.104; failure to provide this results in automatic denial.
• Tax Information: Submission of a W-9 and matching IRS documentation for 1099 tax reporting.
• Application Fee: Payment of the federal Medicaid/Medicare institutional provider application fee, unless proof of payment to Medicare or another state is provided.

6. Staffing, Training and Background Checks

Montana enforces strict personnel standards for staff delivering 24-hour residential care. Direct Support Professionals (DSPs) and facility managers must meet baseline qualifications outlined in the DDP Services Manual and QAD licensing rules.

All staff with direct participant contact must clear comprehensive background checks before providing unsupervised care.

• Background Checks: Mandatory fingerprint-based state and federal criminal history checks, plus checks of the Montana Abuse/Neglect registries.
• Basic Qualifications: DSPs must have a high school diploma or GED and be at least 18 years of age.
• Initial Training: Staff must complete CPR/First Aid certification and division-approved training on abuse/neglect reporting before working independently.
• Medication Administration: Staff administering medications must complete the Montana DPHHS-approved medication aide training program.
• Ongoing Education: Providers must ensure staff complete annual continuing education hours as specified by the facility license type (e.g., 16 hours annually for ALF staff).

7. Documentation, Policies and Records

Providers must maintain exhaustive clinical and administrative records to support Medicaid claims and demonstrate compliance with ARM 37.34.972 (Residential Habilitation).

Records must be retained for a minimum of five years and be immediately available for audit by DPHHS, QAD, or the Medicaid Fraud Control Unit (MFCU).

• Personal Supports Plan (PSP): The facility must maintain a current copy of the member's PSP and document daily progress toward identified goals.
• Service Logs: Daily documentation of the specific habilitation and personal care tasks provided, signed and dated by the DSP.
• Medication Administration Records (MAR): Accurate, up-to-date MARs detailing every dose of medication administered, refused, or missed.
• Incident Reporting: Immediate documentation and reporting of critical incidents (e.g., falls, behavioral crises, allegations of abuse) to DPHHS via the state's incident management system.
• Financial Records: Detailed ledgers of resident funds if the facility acts as a representative payee, kept strictly separate from facility operating funds.

8. Billing, Rates and Claims

Montana Medicaid reimburses HCBS residential services on a Fee-for-Service basis. Claims are submitted electronically to Conduent using the MMIS portal.

Rates are established by DPHHS and published in the division-specific fee schedules. Providers may only bill for days the member was actually present in the facility or receiving authorized therapeutic leave.

• Billing System: Claims must be submitted via the Conduent provider portal or through an approved clearinghouse using standard 837I or 837P formats.
• Prior Authorization: All residential services require an active prior authorization loaded into the MMIS by the waiver case manager before claims will pay.
• Rate Schedules: Reimbursement rates are fixed by DPHHS and published on the provider type pages at medicaidprovider.mt.gov.
• Room and Board: Providers must collect room and board payments directly from the resident; these cannot be billed to Medicaid.
• Timely Filing: Claims must generally be submitted within 365 days of the date of service to be eligible for payment.

9. Approval Sequence and Timeline

Establishing a new residential care service in Montana is a multi-month process due to the sequential nature of physical plant licensing and Medicaid enrollment.

Providers should expect the entire process, from securing a building to receiving the first Medicaid payment, to take between 6 and 9 months.

• Step 1: Business Formation: Register the entity with the MT Secretary of State and obtain an NPI and EIN (1-4 weeks).
• Step 2: Facility Preparation: Secure a location, complete zoning approvals, and pass the Fire Marshal inspection (2-3 months).
• Step 3: QAD Licensure: Submit the licensing application, policies, and undergo the QAD on-site readiness survey (60-90 days).
• Step 4: Division Contracting: Execute the provider agreement with DDP or SLTC (30 days).
• Step 5: Medicaid Enrollment: Submit the Conduent enrollment application with the QAD license and contract attached (30-45 days).

10. Common Denials and Survey Findings

Applications and ongoing licenses are frequently delayed or cited due to incomplete documentation or failure to meet physical plant standards.

QAD and DDP conduct regular surveys, and failure to maintain compliance can result in payment suspensions, directed plans of correction, or license revocation.

• Settings Rule Violations: Denials during initial review if the home is located adjacent to an institution or lacks community integration features.
• Incomplete Ownership Disclosure: Conduent will reject enrollment applications that fail to list all individuals with a 5% or greater ownership interest.
• Background Check Gaps: Survey citations for allowing staff to work before fingerprint background checks are fully cleared.
• Medication Errors: Citations for incomplete MARs or staff administering medications without current DPHHS medication aide certification.
• Missing PSP Documentation: Recoupment of Medicaid funds if daily service logs do not align with the goals and frequencies authorized in the PSP.

11. Key Contacts and Resources

Prospective providers must utilize official DPHHS and Conduent resources to navigate the licensure and enrollment process.

Monitoring the provider portal for updated fee schedules, manual revisions, and Claim Jumper newsletters is essential for maintaining compliance.

• Montana Healthcare Programs Provider Portal: https://medicaidprovider.mt.gov (for enrollment, manuals, and fee schedules).
• Conduent Provider Relations: [email protected] or (800) 624-3958.
• DPHHS Quality Assurance Division (QAD): https://dphhs.mt.gov/qad/ (for facility licensing applications and rules).
• DPHHS Developmental Disabilities Program (DDP): https://dphhs.mt.gov/dsd/developmentaldisabilities/ (for 1915(c) waiver contracting).
• Administrative Rules of Montana (ARM): https://rules.mt.gov (search Title 37 for specific licensure and Medicaid rules).

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