Montana § 53-6-1305 Montana Help Act Program -- Delivery Of Health Care Services -- Third-Party Administrator -- Rulemaking

Montana Statutes

§ 53-6-1305 — Montana Help Act Program -- Delivery Of Health Care Services -- Third-Party Administrator -- Rulemaking

Montana·Title 53 SOCIAL SERVICES AND INSTITUTIONS·Ch. 6 HEALTH CARE SERVICES·Part 13 Montana Health and Economic Livelihood Partnership (HELP) Act

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

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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.
(3) (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.

Montana § 53-6-1305 (Montana Help Act Program -- Delivery Of Health Care Services -- Third-Party Administrator -- Rulemaking) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.