3.1 Montana Health Insurance Policy Requirements

Who Regulates Health Insurance in Montana

Montana health insurance is regulated by the Commissioner of Securities and Insurance (CSI), which is also the Office of the State Auditor. The Commissioner is elected (not appointed) to a four-year term and holds dual title as State Auditor and Insurance Commissioner. The CSI reviews policy forms and rates, licenses producers, and enforces both state law (Title 33, Montana Code Annotated) and the state-administered portions of federal law.

Exam logistics to lock in

The Montana Accident & Health (Disability) producer exam is delivered by Pearson VUE, delivers 110 multiple-choice questions (92 scored: 50 general + 42 Montana, plus 18 pretest), allows 2 hours 15 minutes, and requires a scaled score of 75 to pass. The exam blends a national section and a Montana state-law section into one scaled score. The separate Life exam delivers 103 questions (86 scored) in 2 hours, also passed at a scaled 75. A common trap: Montana reports a scaled score, not a raw percentage, and the fee ($59) is charged per line exam.

The HealthCare.gov Marketplace and Metal Tiers

Montana did not build a state-based exchange and does not use a partnership model; residents enroll through the federal HealthCare.gov platform. Qualified health plans (QHPs) sort into four metal tiers by actuarial value (the share of total covered costs the plan pays for a standard population):

Worked example: A member with $20,000 in covered claims on a Gold plan (80% AV) sees the plan absorb roughly $16,000 of cost across the standard population; the same claims on Bronze (60% AV) shift more to the member. Trap: Cost-sharing reductions only attach to Silver plans for enrollees between 100%-250% of the federal poverty level — picking Bronze forfeits CSRs entirely.

Medicaid Expansion (HELP Act)

Montana expanded Medicaid in 2016 under the HELP Act (Health and Economic Livelihood Partnership), covering adults 19-64 up to 138% of the federal poverty level. In 2025 the Legislature repealed the program's sunset, making expansion permanent (it previously faced a 2025 expiration). Federal H.R. 1 (enacted July 4, 2025) imposes community-engagement ("work") requirements — generally 80 hours per month of work, education, or volunteering, or a qualifying exemption — which Montana DPHHS begins phasing in July 1, 2026, with full implementation required by January 1, 2027.

Pre-Existing Conditions, Guaranteed Issue, Guaranteed Renewal

Under the ACA as enforced in Montana, ACA-compliant plans cannot exclude or surcharge pre-existing conditions, and rating is limited to age (3:1 band), geography, tobacco use, and family size — never health status or gender.

Guaranteed issue means an insurer must accept every applicant for an ACA-compliant plan regardless of health. Guaranteed renewal means coverage continues at the policyholder's option; an insurer may non-renew or rescind only for:

• Non-payment of premium
• Fraud or intentional material misrepresentation
• Plan discontinuation or market withdrawal (with required advance notice)
• Loss of membership in an association (for association plans)

Montana Mental Health Parity Act (MCA 33-22, Part 7)

Montana's own parity statute supplements the federal Mental Health Parity and Addiction Equity Act (MHPAEA). It requires plans to cover mental health conditions and substance use disorders no more restrictively than medical/surgical benefits, and explicitly extends to the psychiatric collaborative care model (also called the primary care behavioral health model). Under MCA 33-22-707, insurers must file parity-compliance reports demonstrating they meet federal comparative analysis duties under 42 U.S.C. 300gg-26(a)(8).

CSI "red flag" parity violations

The Commissioner publishes example violations producers and consumers should recognize:

• Requiring a new treatment plan every 90 days for mental health therapy when no equivalent rule applies to medical care
• Reauthorizing inpatient psychiatric stays every 5 days when surgical stays are not
• Categorically refusing out-of-state mental health treatment
• Denying therapy because progress has not been "proven"

The CSI has ordered insurers to pay denied claims and imposed fines for these practices.

The Ten Essential Health Benefits

Every individual and small-group ACA plan in Montana must cover all ten essential health benefits (EHBs):

1. Ambulatory (outpatient) patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive/wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Trap: Adult dental and vision are not mandatory EHBs — only pediatric oral/vision are guaranteed. Preventive services (item 9) must be covered with no cost sharing when delivered in-network.

Filing a Parity Complaint

Consumers and producers can escalate suspected parity violations to the CSI:

The Commissioner investigates, can compel claim payment, and can fine or sanction the insurer.