Montana is one of the most rapidly aging states in the nation, with approximately 19.7% of its 1.1 million residents now aged 65 and older, compared to the national average of 16.8%. The state ranks among the top 15 states for the proportion of seniors in its population, and by 2030, residents aged 65 and older are projected to constitute nearly 25% of the population. Montana is expected to rank 5th in the nation by 2030 in its percentage of residents 65 and older at 25.8%, trailing only Florida, Maine, New Mexico, and Wyoming.

This demographic shift, combined with Montana's vast rural geography where 54 out of 56 counties are designated Health Professional Shortage Areas, creates both tremendous demand and significant challenges for home health agencies. This guide covers everything agencies need to know about providing home health services in Montana, from DPHHS licensing requirements to the Big Sky Waiver program and strategies for building a sustainable caregiver workforce in one of the nation's most rural states.

Montana Home Health Agency Licensing Requirements

To operate a home health agency in Montana legally, providers must obtain licensure through the Montana Department of Public Health and Human Services (DPHHS). The DPHHS Bureau of Licensure oversees health care facility licensing under the authority of Montana Code Annotated (MCA) and Administrative Rules of Montana (ARM).

Licensing authority. DPHHS Licensure's mission is to protect the safety and well-being of Montanans through the licensing of Montana child, youth, and health care facilities. The Bureau can be reached at (406) 444-2037 for licensing questions.

Application process. The licensing process involves submitting the DPHHS Home Care License Application available from the DPHHS website, passing a site inspection where a DPHHS representative reviews your office and recordkeeping practices, and paying applicable license fees which vary depending on care level and number of clients. The licensing process typically takes 60-90 days or more depending on processing time and application accuracy.

Staff requirements. DPHHS and Medicaid regulations require that home care agency employees meet specific eligibility and training criteria. All staff must pass a fingerprint-based FBI background check and Montana criminal history check. CPR and First Aid certification is typically required for all field staff. TB testing is recommended prior to employment. Staff must also complete state-approved training covering personal care, safety, and infection control.

Plans of care. All home health plans of care must be reviewed by the ordering physician at least every 60 days. Services must be delivered in the member's residence on the physician's orders as part of a written plan of care.

Medicaid provider enrollment. If you plan to serve Medicaid clients, you must be certified as a Medicaid provider through Montana's Medicaid program. This process includes additional documentation and verification to ensure your agency meets federal and state care standards. Provider enrollment is managed through the Montana Medicaid Provider website at medicaidprovider.mt.gov.

Electronic Visit Verification. Per Section 12006 of the 21st Century Cures Act, Montana has implemented Electronic Visit Verification (EVV) systems for all personal care services and home health services requiring in-home visits. EVV provider full compliance has been required since July 1, 2024. Montana DPHHS uses Netsmart's Mobile Caregiver+ as its state EVV solution, which is available free to providers. EVV must record at least six aspects of service delivery: the date of service, starting location, ending location, type of service, the individual providing the service, the individual receiving the service, and the start and end times of the service.

Alternate EVV systems. Montana uses an Open Vendor model for EVV. Providers with existing EVV systems that meet DPHHS compliance requirements and are certified by DPHHS can continue using their systems. However, alternate vendors must integrate with Netsmart Mobile Caregiver+ and send visit data as required by Montana DPHHS. For EVV assistance, contact the call center at (833) 483-5587 from 7am to 6pm Mountain Time, or email [email protected].

Penalties for non-compliance. Failure to comply with EVV requirements can result in penalties such as reduced reimbursement rates, termination of Medicaid provider status, and denial of payment for services.

Home Health Aide Certification Requirements

Montana has a unique approach to home health aide certification that requires HHAs to first obtain Certified Nursing Assistant (CNA) certification, then complete additional specialized training. This ensures a standardized baseline of competency across the state's direct care workforce.

Training pathway. To become a certified home health aide in Montana, candidates must first complete CNA certification (75 hours minimum), then complete an additional 16 hours of HHA-specific training. The total minimum training requirement is 91 hours. Montana is unusual in that standards for Certified Nurse Aides are set at the minimum national level while standards for Home Health Aides are set at a higher level, with HHA regarded as an additional endorsement.

CNA requirement. Montana requires home health aides to hold current CNA certification before obtaining the HHA endorsement. HHAs must be registered with the Montana Nurse Aide Registry. This registry is managed by DPHHS and can be accessed through the BOUNDS online portal.

HHA endorsement. For a Home Health Aide Endorsement, candidates need to have a Montana Certified Nurse Aide Certificate and participate in specific Home Health Aide training. The application process is handled through the Nurse Aide Registry.

Educational prerequisites. Training programs typically require a high school diploma or GED, criminal background check, drug test, tuberculosis skin test, and physical exam.

Continuing education. Home Health Aides are required to complete 12 hours of continuing education annually to meet federal requirements. This applies to all HHAs working in Medicare or Medicaid certified settings.

Salary expectations. In Montana, the average home health aide salary is approximately $31,600 per year, slightly below the national average of $34,990. Entry-level positions may start lower, with wages varying based on experience, location, and employer.

Certified Nursing Assistant (CNA) Requirements

Since Montana requires HHAs to hold CNA certification, understanding these requirements is essential for all home health workers in the state. CNAs in Montana are credentialed by the Montana Department of Public Health and Human Services.

Training program structure. CNA programs must include at least 75 hours of instruction, with a minimum of 25 hours of supervised clinical practice. After training, the program enters the candidate's record into the Montana TestMaster Universe (TMU) system operated by D&SDT-Headmaster.

Competency examination. There are two parts to the nurse aide competency examination: a multiple-choice knowledge test and a skill test. The written section is 75 questions in length with 90 minutes to complete. The skills evaluation is a 40-minute time period to complete four selected nurse aide skills. Exam candidates must be registered, complete approved training, pass both parts of the exam, and meet all other DPHHS requirements to qualify for certification.

Application process. All Certified Nurse Aide Applications are now online through the BOUNDS portal. PDF and paper applications are no longer accepted. Those who have completed an approved Montana Nurse Aide Training Program and successfully passed the Montana Certified Nurse Aide exams must complete an online BOUNDS Montana CNA by Exam Application at the BOUNDS Portal.

Certification duration. Active placement on the nurse aide registry is good for two years. To maintain certification, CNAs must provide proof of working at least 8 hours as a paid CNA within the two years preceding certification expiration.

Renewal requirements. Certificates can be renewed starting 90 days prior to expiration. Renewals completed through the BOUNDS portal are processed automatically. CNAs must document at least 8 hours of paid CNA employment in the past 24 months. If you cannot provide proof of the required work hours, you must complete both the written and skills tests again to be recertified.

Interstate endorsement. CNAs can be endorsed into Montana on the basis of certification in any state. Submit the Interstate Endorsement Application in the BOUNDS portal with proof of at least one current out-of-state CNA certificate. The Nurse Aide Registry will also require a card or letter from each state of certification. No fees are due with the application.

Challenging the exam. Nursing students who have successfully completed one semester of an accredited nursing program may challenge the CNA exam without completing a CNA training program.

Contact information. The Montana Nurse Aide Registry can be reached Monday through Friday, 8:00 AM to 5:00 PM Mountain Time at (406) 444-4980. For exam questions, call Headmaster at (800) 393-8664.

Medicaid Reimbursement in Montana

Montana's Medicaid program provides home and community-based services through both the State Plan and Section 1915(c) waivers. Unlike many states, Montana does not have Medicaid-managed care; the state contracts directly with providers and pays in a variety of ways, with many outpatient services paid fee-for-service.

Big Sky Waiver. The Big Sky Waiver (BSW) is Montana's primary HCBS waiver supporting elderly individuals and adults with physical disabilities who require a nursing home level of care but choose to live at home or in the community. This includes assisted living facilities and adult foster care homes. Services include private duty nursing, home modifications, specialized medical equipment, adult day health care, and personal care assistance. Participants can select the caregiver of their choosing, including their adult child or spouse. The Big Sky Waiver Program has approximately 2,800 enrollment slots per year as of 2025.

Waitlist challenges. Montana's Medicaid home and community-based services waiver program currently has a waitlist that is years long. The current waitlist for an HCBS 0208 waiver sits at approximately 2,394 people. DPHHS is able to move only around 10 people per month from the waitlist to a waiver. Unlike State Plan services, the Big Sky Waiver is not an entitlement; once enrollment slots are filled, those in need are placed on a waitlist.

Community First Choice. Montana also offers the Community First Choice/Personal Assistance Services Program for eligible Medicaid beneficiaries who need help with activities of daily living. This program, along with the Big Sky Waiver, represents the primary pathways for Medicaid payment of home care services.

Reimbursement rate challenges. A Guidehouse study conducted for DPHHS indicates that Montana Medicaid reimbursement rates average 25% below what providers require to stay afloat. Governor Gianforte proposed increasing rates by only 36% of the recommended amount. This gap between actual costs and reimbursement creates significant pressure on home health agencies serving Medicaid beneficiaries.

Fee schedule updates. Montana DPHHS announced July 1, 2025 fee schedule updates on June 25, 2025. The Montana Medicaid Provider website maintains current and proposed fee schedules, including home health services and Big Sky Waiver fee schedules. Providers should bill their usual and customary charges, as the fee schedule sets maximum allowable amounts.

Home health services coverage. Covered home health services include physical therapy, occupational therapy, and speech pathology services provided by a licensed home health agency or facility. Home health aide services are covered when aide services are not available through a Medicaid personal assistance program such as Community First Choice.

Contact for rates. For current fee schedule information, access the Montana Medicaid Provider website at medicaidprovider.mt.gov. Proposed fee schedules are available at medicaidprovider.mt.gov/proposedfs.

Medicare Home Health Coverage

With Montana's significant elderly population growth, Medicare remains a crucial payer for home health services. Medicare certification can help agencies access a broader patient base and diversify their payer mix beyond Medicaid.

Eligibility requirements. To qualify for Medicare home health coverage, beneficiaries must be homebound (leaving home requires considerable effort due to illness or injury), need skilled nursing care on an intermittent basis or require physical therapy, speech-language pathology services, or continued occupational therapy, have a physician certify the need for home health care and establish a plan of care, and receive services from a Medicare-certified home health agency.

2025 rate updates. CMS's Calendar Year 2025 Home Health Prospective Payment System Final Rule set the 30-day standard payment rate at $2,057.35, up from $2,038.15 in 2024. Medicare payments to home health agencies in 2025 are estimated to increase in aggregate by 0.5%, or $85 million, compared to 2024. The 2.7% market basket update is offset by productivity adjustments.

Plan of care requirements. Medicare requires a plan of care signed by a physician that specifies the services needed, frequency, and duration. The plan must be reviewed at least every 60 days, consistent with Montana's state requirements for Medicaid services.

Payer diversification. Given the challenges with Montana Medicaid reimbursement rates and waiver waitlists, Medicare certification offers agencies an important pathway to serve more patients and improve financial sustainability.

Labor Laws and Wage Requirements

Montana has notable labor law protections that differ from many other states, including a higher minimum wage than the federal floor and strong worker protections.

State minimum wage. Montana's minimum wage is $10.55 per hour effective January 1, 2025. This is adjusted annually by September 30 based on the Consumer Price Index. If the federal minimum wage is higher, it applies instead. For businesses not covered by the Fair Labor Standards Act whose gross annual sales are $110,000 or less, a lower rate of $4.00 per hour may apply, but this exception rarely affects home health agencies.

No tip credit. Unlike many states, Montana law does not allow employers to pay tipped employees a lower minimum wage. No tip credit, meal credit, or training wage is allowed under Montana's Wage and Hour Laws. Tipped employees are entitled to the full minimum wage for every hour worked.

Overtime requirements. Montana follows federal FLSA overtime rules. Overtime must be paid at 1.5 times the regular rate for all hours worked over 40 in a workweek. Montana does not have daily overtime requirements, only weekly. Bona fide executive, administrative, professional, or skilled computer employees earning at least $27.63 per hour are exempt from overtime.

Overtime salary threshold. Under updated FLSA rules, the minimum salary threshold for exempt employees increased to $58,656 annually ($1,128 per week) as of January 1, 2025. Employees earning less than this threshold are entitled to overtime regardless of job duties.

Breaks and meals. Montana employers are not required to provide meal or rest breaks for adult employees. However, employees must be paid if they have to do any work during a break. Generally, employees are entitled to be paid for any short breaks (five to 20 minutes) the employer provides, as this time is considered part of the work day.

Overtime exemptions. Twenty-five types of workers are exempt from Montana overtime requirements, including agricultural workers, certain salespeople, and taxi drivers. Home health workers are generally not exempt and are entitled to overtime pay.

Montana's Workforce Challenges

Montana faces significant home health workforce challenges driven by its rapidly aging population, vast rural geography, healthcare professional shortages, and competition from other sectors. Understanding these dynamics is essential for agencies developing recruitment strategies.

Aging population surge. Montana's 65+ population has increased by 46.8% from 2010 to 2021, with 19.6% of the population now aged 65 and older. By 2030, seniors will represent nearly 25% of the state's population. The state's eastern counties will experience the largest increases, with 10 of the 15 counties projected to have 65-and-older populations of 26% or higher by 2025.

Declining worker-to-retiree ratio. Today, there are approximately four people of working age for each elderly person in Montana. However, projections estimate that by 2030 the ratio will reduce to only two working-age people for each elderly person, creating unprecedented demand for caregivers who can meet increasingly complex care needs. The current old-age dependency ratio is 31.4 persons aged 65+ per 100 persons aged 15-64.

Health professional shortage areas. In Montana, 54 out of 56 counties are designated Primary Care Health Professional Shortage Areas. Except for Yellowstone County, the entire state is considered a mental health shortage area. There are 13 Montana counties without primary care physicians, 10 counties without dentists, and 46 counties without psychiatrists. One in five Montanans deals with depression.

Transportation barriers. For the 13 counties without primary care physicians, drive times to reach the nearest physician range from approximately 27 minutes for Wibaux County residents to well over an hour for residents in Garfield County. Access to behavioral health services in rural and frontier settings is impeded by limited resource availability, economic issues, caregiver stress and isolation, and the need to travel long distances.

Family caregiver burden. There are approximately 112,000 family caregivers in Montana who provide $1.76 billion in unpaid care each year. Among these caregivers, 47% report financial setbacks such as taking on debt, draining savings, or struggling to afford basics like food and medicine. 54% are also juggling full- or part-time jobs alongside their caregiving responsibilities.

State ranking decline. According to AARP's Long-Term Services and Supports scorecard, Montana ranks #33 in the country for long-term care services. Major gaps persist in Safety and Quality, Choice of Setting and Provider, and Affordability and Access. Montana dropped six slots since the last scorecard was issued in 2021, when Montana was ranked #27.

Workforce shortage projections. Personal care jobs are among the ten occupational groups with the highest annual projected occupation demand in Montana. Personal care aides' opening job projections rank first among non-health care jobs within the healthcare industry. The Montana State Plan on Aging recognizes that workforce shortage will continue to be a significant challenge, with unfilled positions and chronic understaffing directly impacting service delivery.

High turnover linked to wages. The Montana Healthcare Workforce Strategic Plan recognizes that high turnover rates are linked to low wages, limited or no benefits, and inadequate training. Industry-wide, caregiver turnover rates reach 75-80% annually nationally.

Strategies for Montana Agencies

Given Montana's specific market dynamics, agencies must adopt targeted strategies to recruit and retain caregivers in a challenging environment characterized by vast distances, aging populations, and healthcare workforce shortages.

Pay competitively above minimum. With Montana's $10.55 minimum wage, paying significantly above minimum is essential for recruitment. The state average of approximately $31,600 annually ($15.19/hour) for HHAs means competitive agencies may need to exceed $16-17 per hour to attract quality caregivers, particularly in areas competing with other industries.

Build rural recruiting strategies. Montana's vast rural geography requires creative approaches. Consider recruiting locally in smaller communities rather than expecting workers to commute from urban areas. Partner with local community organizations, churches, and schools. Travel time reimbursement and mileage payments can make rural assignments more attractive for caregivers who must drive significant distances between clients.

Leverage telemedicine integration. Montana has invested in telemedicine technology to address the shortage of doctors in rural areas. Home health agencies can integrate telehealth capabilities to extend service reach, provide supervision for aides in remote areas, and improve care coordination without requiring extensive travel.

Partner with training programs. Montana Tech, University of Montana, and various community colleges offer CNA programs. Building relationships with these programs is essential since Montana requires CNA certification before HHA endorsement. Consider tuition sponsorship or guaranteed employment upon completion to build your recruitment pipeline.

Emphasize career pathways. The lack of career advancement is a documented retention barrier. Create clear pathways from HHA to higher certifications. Partner with nursing programs that have expanded in Montana (the number of primary care residency programs increased from one to four over the past five years). Offer tuition assistance tied to employment commitments.

Address benefits gaps. Many Montana caregivers lack benefits. Even modest offerings such as paid time off, health insurance contributions, or retirement matching can differentiate your agency. Some agencies offer same-day pay options to address financial stress among workers, particularly given that 47% of family caregivers report financial setbacks.

Focus on retention. Given recruiting challenges and the chronic understaffing plaguing the industry, every retained caregiver saves significant replacement costs. Invest in thorough onboarding, consistent scheduling, supervisor support, and recognition programs. Exit interviews can identify fixable issues driving turnover.

Support nurse practitioners and PAs. Nurse practitioners and physician assistants play a crucial role in addressing the physician shortage in Montana. Building relationships with these mid-level providers can expand your referral network and improve care coordination in underserved areas.

Monitor Medicaid developments. Stay engaged with DPHHS announcements and legislative developments affecting rates. Given that Medicaid rates are reportedly 25% below what providers need to operate sustainably, diversifying your payer mix and advocating for rate increases are both important strategies.

Build community connections. Montana's communities value local relationships. Word-of-mouth referrals often work better than job boards in smaller markets. Employee referral bonuses, community event sponsorship, and partnerships with local organizations can strengthen your recruiting pipeline in a state where personal connections matter.

Key Resources and Contacts

Agencies operating in Montana should maintain relationships with these key regulatory and support organizations:

Montana Department of Public Health and Human Services - Bureau of Licensure
Health care facility licensing
Phone: (406) 444-2037
Website: dphhs.mt.gov/qad/licensure

Montana Nurse Aide Registry
CNA certification and HHA endorsement
Phone: (406) 444-4980
Hours: Monday-Friday, 8:00 AM - 5:00 PM Mountain Time
Online portal: BOUNDS Portal

CNA Examination (Headmaster)
Competency exam questions
Phone: (800) 393-8664

Montana Medicaid Provider Enrollment
Website: medicaidprovider.mt.gov
Fee schedules: medicaidprovider.mt.gov/proposedfs

Montana DPHHS - Senior and Long Term Care Division
Big Sky Waiver and HCBS programs
Website: dphhs.mt.gov/sltc
Home and Community Based Services: dphhs.mt.gov/hcbs

Electronic Visit Verification (EVV)
Netsmart Mobile Caregiver+ Support
Phone: (833) 483-5587 (7 AM - 6 PM MT)
Email: [email protected]
Website: dphhs.mt.gov/SLTC/EVV

Montana Department of Labor and Industry
Wage and hour questions
Website: erd.dli.mt.gov/labor-standards

Montana Primary Care Office
Health Professional Shortage Area designations
Website: dphhs.mt.gov/ecfsd/primarycare/ShortageAreaDesignations

The Bottom Line

Montana presents unique opportunities and challenges for home health agencies. The state's rapidly aging population, with nearly 20% of residents already over 65 and projections for 25% by 2030, ensures sustained demand for services. Montana will rank 5th in the nation for its percentage of elderly residents by decade's end, creating a substantial and growing market for home health services.

However, the workforce challenge is severe. With 54 of 56 counties designated as Health Professional Shortage Areas, 13 counties without primary care physicians, and vast distances between communities, recruiting and retaining caregivers requires innovative approaches. The declining ratio of workers to retirees, moving from 4:1 today toward 2:1 by 2030, means competition for all workers will intensify across industries.

The Medicaid landscape adds complexity. The Big Sky Waiver waitlist of nearly 2,400 people with only 10 slots opening monthly, combined with reimbursement rates that a state-commissioned study found to be 25% below sustainable levels, creates financial pressure for agencies serving Medicaid beneficiaries. Payer diversification through Medicare certification and private pay clients is increasingly important for sustainability.

Success in Montana requires understanding the DPHHS licensing framework, navigating both the Big Sky Waiver and Community First Choice programs effectively, paying competitively above the $10.55 state minimum wage, developing creative recruiting strategies for rural and frontier markets, and building retention programs that address the specific challenges of Montana's workforce environment. Agencies that invest in competitive wages, build strong training partnerships with Montana's expanding nursing programs, create career pathways, leverage telemedicine for rural service delivery, and develop supportive workplace cultures will be best positioned to serve Montana's growing senior population while building sustainable businesses in Big Sky Country.