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Now that Medicaid expansion is law in Montana, the real work of making it happen begins -- and state health officials said Wednesday it certainly won’t happen overnight.

The state first must prepare and submit a “waiver” for approval by the federal government, before Montana’s plan to expand Medicaid to thousands of low-income Montanans can begin and be funded.

And, if that approval occurs, the state then must hire a private health-insurance company to manage the expansion, choosing from whoever decides to bid on the multimillion-dollar contract.

How long will this series of hurdles take to clear, and the federal Medicaid money start flowing in Montana, providing coverage to thousands?

State health officials are making no predictions. But, they indicated Wednesday it’s going to be at least a few months.

“Everything flows from the waiver being approved,” said Mary Dalton, Medicaid branch manager for the state Department of Public Health and Human Services. “We will work diligently to get this done. We are committed to getting health care to people as soon as we can.”

Senate Bill 405, signed Wednesday by Gov. Steve Bullock, authorizes the state to expand federal Medicaid coverage to all able-bodied adults earning up to 138 percent of the federal poverty level, about $16,200 a year for a single person. The income ceiling is adjusted upward according to family size.

Under the federal Affordable Care Act, the federal government pays the entire cost of this expansion through 2016, and then gradually ramps down its share to 90 percent by 2020.

It’s estimated that Montana’s share of federal Medicaid-expansion funds could be anywhere from $400 million to $700 million over the next two years.

However, if a state doesn’t simply extend its current Medicaid program to this new population, with no new strings attached, it must get the “waiver” from the feds to get the money.

SB405 attaches several strings, such as a requirement that newly covered adults must pay a small premium -- 2 percent of their income. The program also will be managed by a “third party administrator,” which is a private insurer.

Dalton said no other state in the nation has proposed the third-party administrator arrangement.

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The state will start working now on the waiver, which, when drafted, will have two months for public comment and a public hearing, she said.

Jessica Rhoades, head of intergovernmental relations for DPHHS, said Montana’s plan is considered a “research and demonstration” project because it deviates from standard Medicaid.

Montana must demonstrate to federal health officials that its plan will provide health coverage equal to other Montanans covered by Medicaid, she said.

Dalton said she’s not sure what parts of Montana’s plan may face the most scrutiny, but that she doesn’t see anything that’s “insurmountable.”

The waiver will be submitted to the Center on Medicare and Medicaid Services in Washington, D.C., a division of the U.S. Department of Health and Human Services. The agencies and the Obama administration make the final call on whether to approve Medicaid waivers.

CMS officials didn’t respond Wednesday to a request for comment. However, in the past, they’ve said they’re “committed to working with states to design programs uniquely their own, while maintaining essential health benefits guaranteed under the ACA and other key consumer protections consistent with the law.”

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