53-6-1305. Montana HELP Act program -- delivery of health care services -- third-party administrator -- rulemaking.
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53-6-1305 . Montana HELP Act program -- delivery of health care services -- third-party administrator -- rulemaking.
(1)The department may contract as provided in Title 18, chapter 4, with one or more third-party administrators to assist in administering the delivery of health care services to members eligible under 53-6-1304 , including but not limited to:
(a)establishing networks of health care providers;
(b)paying claims submitted by health care providers;
(c)collecting the premiums provided for in 53-6-1307 ;
(d)coordinating care;
(e)helping to administer the program; and
(f)helping to administer the medicaid program reforms as specified in 53-6-1311 .
(2)If the department decides to contract with a third-party administrator, the department shall determine the basic health care services to be provided through the arrangement with the third-party administrator.
(a)The department may exempt certain individuals who are eligible for medicaid-funded services pursuant to 53-6-1304 from receiving health care services through an arrangement with a third-party administrator if the individuals would be served more appropriately through the medical assistance program established in Title 53, chapter 6, part 1.
(b)If the department contracts with a third-party administrator, the department shall:
(i)adopt rules establishing criteria for determining whether a member is exempt from receiving health care services through an arrangement with the third-party administrator;
(ii)provide coverage for exempted individuals through the medical assistance program established in Title 53, chapter 6, part 1; and
(iii)for members participating in the arrangement with a third-party administrator, directly cover any service required under federal or state law that is not available through the arrangement with the third-party administrator.
(4)The department may contract with a third-party administrator for the services allowed under subsections (1)(a) through (1)(f) only upon receipt of a federal waiver allowing a third-party administrator to provide services in accordance with this part.