What is the Big Sky Waiver?
The Big Sky Waiver (BSW) is a Montana Medicaid 1915(c) Home and Community Based Services waiver run by the Department of Public Health and Human Services (DPHHS), Senior and Long Term Care Division. It exists so that Montanans who would otherwise need a nursing facility can instead receive care in their own home or community. Personal assistance is one of the core services the waiver pays for, alongside case management, homemaker services, respite, adult day health, home modifications, and specialized medical equipment.
What makes the Big Sky Waiver valuable for families is its self-directed option. Instead of an agency assigning a stranger, the participant becomes the employer: they recruit, hire, train, schedule, and if necessary fire their own personal care attendant. Montana lets that attendant be a family member, and unlike most states, the Big Sky Waiver does not automatically bar a spouse from being the paid caregiver. An adult child, sibling, in-law, friend, or spouse who has been quietly providing care can finally be paid for it.
Because the waiver is a formal employment arrangement, a Financial Management Services (FMS) agency sits behind the scenes. The FMS agency handles the parts most families do not want to manage: issuing paychecks, withholding and filing payroll taxes, running background checks on the caregiver, and keeping the paperwork compliant with Medicaid rules. The participant still controls who does the caregiving and when; the FMS agency just makes the payroll legal and reliable.
It is important to know that the Big Sky Waiver is not an entitlement. Montana funds a limited number of slots each year (roughly 2,500 statewide), so when the program is full there can be a waiting list. This is different from Montana's Community First Choice (CFC) and Personal Care Services (PCS) state plan options, which are entitlements available to anyone who qualifies - but which do not let a spouse be the paid caregiver. Many families use CFC/PCS while waiting for a Big Sky Waiver slot.
Big Sky Waiver eligibility requirements
To use the Big Sky Waiver, the person receiving care must qualify for Montana Medicaid, need a nursing-facility level of care, and secure one of the waiver's limited slots. The family caregiver does not need to meet income or asset limits - only the Medicaid member does.
Who can - and cannot - be paid as a caregiver
The Big Sky Waiver's self-directed option is unusually generous about family: the participant chooses their own attendant, and a spouse or adult child can be hired. The rules are stricter under Montana's separate CFC / PCS state plan programs, so it matters which program you are enrolled in.
- A spouse (allowed under the self-directed Big Sky Waiver - a key difference from most states and from Montana's own CFC/PCS)
- Adult children (18 or older) of the participant
- Siblings, grandchildren, nieces, nephews, aunts, uncles, and in-laws
- Ex-spouses and step-relatives
- Close friends, neighbors, or other trusted individuals
- A spouse, parent, or legal guardian IF the member is served through the CFC or PCS state plan option instead of the Big Sky Waiver
- A parent of a minor child (under 18) receiving the care
- Anyone the participant is not willing or able to direct and supervise as the employer
- A caregiver who fails the required background check run by the Financial Management Services agency
Big Sky Waiver pay, hours, and overtime
Montana sets personal assistance reimbursement rates through its published Medicaid fee schedules, and the number of authorized hours depends on the participant's assessed needs. Pay lands in the general range of what home care aides earn in Montana.
Hourly pay
Montana does not publish a single flat "family caregiver wage." Personal assistance is paid from the state's Big Sky Waiver fee schedule (updated by DPHHS, most recently in July 2025), and the take-home rate for a self-directed attendant generally falls in the range of about $14 to $20 per hour in 2025-2026, in line with prevailing home care aide wages across Montana. The exact amount depends on the fee schedule, the FMS agency's administrative share, and the region. The caregiver is a W-2 employee of the arrangement, so payroll taxes are withheld and filed by the FMS agency.
Hours and scheduling
Authorized hours are based on the nurse assessment of the participant's needs, not a fixed weekly cap. Someone with moderate needs might be authorized for a handful of hours a day, while a participant with extensive ADL needs may receive substantially more. Hours can be split among more than one caregiver - for example, two adult children (or a spouse and an adult child) sharing the week.
Overtime rules
Federal Fair Labor Standards Act rules apply to home care workers, so a caregiver who works more than 40 hours in a single workweek for one participant is generally owed overtime at 1.5x the regular rate. The Financial Management Services agency tracks hours and handles overtime and tax compliance; families with high authorized hours often use two caregivers to keep any single worker under the overtime threshold.
How to apply for the Big Sky Waiver in Montana
- Apply for Montana Medicaid if the person receiving care is not already enrolled. Apply online at apply.mt.gov, in person at a local Office of Public Assistance, or by phone.
- Montana Public Assistance Helpline: 1-888-706-1535
- Have income, asset, residency, and identity documents ready
- Ask specifically about long-term care / HCBS Medicaid, not just standard coverage
- Request a level-of-care assessment. A registered nurse through Mountain Pacific Quality Health will evaluate whether the person meets nursing-facility level of care based on their ADL and IADL needs.
- Mountain Pacific Quality Health: 1-800-219-7035 (or 406-443-4020)
- Be ready to describe help needed with bathing, dressing, transfers, toileting, and eating
- Contact the DPHHS Senior and Long Term Care Division to start the Big Sky Waiver process and confirm slot availability. If all slots are full, ask to be placed on the waiting list and to use CFC or PCS in the meantime.
- Senior and Long Term Care Division: 406-444-4077
- Work with your assigned case manager to build a person-centered plan of care. The plan documents your authorized personal assistance hours and confirms you want the self-directed option so you can hire your own family caregiver.
- Enroll your caregiver with the Financial Management Services (FMS) agency. The FMS agency runs the background check and sets up payroll.
- Federal I-9 employment verification and W-4 tax forms
- Criminal background check
- Direct deposit setup
- Submit timesheets each pay period. The participant (or their representative) approves the hours the caregiver worked, and the FMS agency issues the paycheck and handles tax withholding. Care plans are reassessed periodically to confirm continued eligibility and adjust hours.
Big Sky Waiver Montana frequently asked questions
Can my spouse be paid to care for me in Montana?
Under the self-directed Big Sky Waiver, yes - this is one of the things that makes Montana's waiver stand out. Because Big Sky Waiver participants can hire, manage, and even fire the caregiver of their choosing, a spouse can be that paid caregiver, along with an adult child, other relative, or friend. That is different from most states, which specifically bar spouses. Be careful about which Montana program you are in, though: Montana's Community First Choice (CFC) and Personal Care Services (PCS) state plan options do NOT allow a spouse (or a parent, or a legal guardian) to be the paid attendant - under CFC/PCS only relatives like adult children or ex-spouses qualify. So if paying a spouse is your goal, the Big Sky Waiver is the route to ask about. Confirm current rules with the DPHHS Senior and Long Term Care Division at 406-444-4077.
How much does the Big Sky Waiver pay a family caregiver in 2026?
Montana pays personal assistance from its published Big Sky Waiver fee schedule (last updated by DPHHS in July 2025) rather than a single advertised "caregiver salary." In practice, a self-directed attendant's take-home pay generally lands in the range of about $14 to $20 per hour in 2025-2026, roughly in line with what home care aides earn across Montana. The exact figure depends on the state fee schedule, the region, and the administrative share taken by the Financial Management Services agency that runs payroll. Because the caregiver is treated as a W-2 employee, federal and state payroll taxes are withheld and filed for them, and the total number of paid hours is set by the participant's assessed needs rather than a flat weekly amount. For an exact current rate, ask your case manager or the FMS agency you are assigned to.
How long does Big Sky Waiver approval take?
Plan for roughly two to three months, and sometimes longer. There are several steps that each take time: establishing Montana Medicaid financial eligibility through the Office of Public Assistance, completing the nursing-facility level-of-care assessment through Mountain Pacific Quality Health, and then getting a Big Sky Waiver slot assigned through DPHHS. If the person is not yet on Medicaid at all, add more time for that application. The biggest wild card is the waiver's limited slots - the Big Sky Waiver is not an entitlement, so if the program is full you may be placed on a waiting list before enrollment can proceed. To keep care going while you wait, ask about Montana's CFC or PCS state plan programs, which have no slot cap. Gathering your income, asset, residency, and medical documents in advance is the best way to speed things up.
What training or certification does the caregiver need?
One of the advantages of self-direction is that no formal certification is required to be a paid family caregiver. Your attendant does not need to be a Certified Nursing Assistant (CNA), a Home Health Aide (HHA), or a licensed nurse. The participant (or their representative) trains the caregiver on the specific tasks they need help with, since the participant is the employer. There are some baseline requirements handled through the Financial Management Services agency - most importantly a criminal background check, plus standard employment paperwork such as an I-9 and a W-4. For certain skilled tasks that may be part of a care plan (for example, some medication assistance or personal-care procedures), the case manager will explain any additional training or documentation Montana requires. But there is no clinical exam or licensing hurdle to clear before a family member can start being paid.
What is the difference between the Big Sky Waiver and Community First Choice (CFC)?
Both are Montana Medicaid programs that pay for personal care at home, but they work differently. The Big Sky Waiver is a 1915(c) HCBS waiver with a limited number of slots and a nursing-facility level-of-care requirement; through its self-directed option a spouse can be the paid caregiver. Community First Choice (a 1915(k) state plan option) and Personal Care Services (a state plan option with a lower "medically necessary" threshold) are entitlements - meaning anyone who qualifies can enroll with no waiting list. The tradeoff is that CFC and PCS do not let a spouse, parent, or legal guardian be the paid attendant, though adult children and some other relatives can be. Many Montana families start on CFC or PCS for immediate, guaranteed coverage and pursue a Big Sky Waiver slot when they specifically need a spouse to be paid or need the broader set of waiver services.
Can I be paid to care for more than one family member?
Yes, in principle a caregiver can provide paid personal assistance to more than one Medicaid participant, but each participant is a separate authorization and a separate employment arrangement through the Financial Management Services agency. The hours you are paid for are tied to each individual's assessed needs, and overtime under the federal Fair Labor Standards Act is generally calculated per employer/participant. That means caring for two people does not automatically combine into overtime, but if your total hours for a single participant exceed 40 in a workweek, overtime rules apply for that person. If you are considering caring for two relatives, tell your case manager and the FMS agency so the paperwork, timesheets, and tax withholding are set up correctly for each one. Families juggling multiple relatives should also confirm how the Big Sky Waiver slot limits affect each person's enrollment.
Does the Big Sky Waiver have a waiting list?
It can. The Big Sky Waiver is not an entitlement - Montana funds a capped number of slots each year (roughly 2,500 statewide), so when the program is full, new applicants may be placed on a waiting list until a slot opens. Waiting times vary depending on demand and available funding, and the state manages the list through the DPHHS Senior and Long Term Care Division. The good news is that you are not stuck without options while you wait: Montana's Community First Choice (CFC) and Personal Care Services (PCS) programs are state plan entitlements with no slot cap, so they can provide personal care right away for people who qualify. The main limitation is that CFC/PCS will not pay a spouse. Ask your case manager to enroll you in CFC or PCS for immediate coverage and to add you to the Big Sky Waiver list at the same time.
Who handles payroll, taxes, and paychecks for the caregiver?
A Financial Management Services (FMS) agency does. In Montana's self-directed Big Sky Waiver, the participant is the employer who decides who provides care and when, but the FMS agency takes care of the administrative and legal side. That includes issuing the caregiver's paychecks, withholding and filing federal and state payroll taxes, running the required criminal background check, and keeping employment records compliant with Medicaid rules. This structure lets a family member get paid legitimately, as a W-2 employee, without the participant having to become a payroll expert. You submit timesheets each pay period, the participant (or their designated representative) approves the hours worked, and the FMS agency turns that into a proper paycheck. Your DPHHS case manager will connect you with the FMS agency serving your area and walk you and your caregiver through the enrollment paperwork.
See also: Montana caregiver guide
For all the ways to get paid to care for a family member in Montana — including Big Sky Waiver, VA programs, long-term care insurance, and more — read the full Montana guide.