§ 53-6-705 — Requirements For Managed Health Care Entities

53-6-705 . Requirements for managed health care entities. (1) A managed health care entity that contracts with the department for the provision of services under the program shall comply with the requirements of this section for purposes of the program.
(2) The entity shall provide for reimbursement for health care providers for emergency care, as defined by the department by rule, that must be provided to its enrollees, including emergency room screening services and urgent care that it authorizes for its enrollees, regardless of the provider's affiliation with the managed health care entity. Health care providers must be reimbursed for emergency care in an amount not less than the department's rates for those medical services rendered by health care providers who are not under contract with the entity to enrollees of the entity.
(3) The entity shall maintain a network of health care providers that is sufficient in number and type to ensure that the services approved by the department for delivery to medicaid recipients covered by the entity are available without unreasonable delay as required under the network adequacy and quality assurance provisions of Title 33, chapter 36, and any rules promulgated under that chapter.
(4) The entity shall provide that any health care provider affiliated with a managed health care entity may also provide services on a fee-for-service basis to department clients who are not enrolled in a managed health care entity.
(5) The entity shall provide client education services as determined and approved by the department, including but not limited to the following services:
(a) education regarding appropriate use of health care services in a managed care system;
(b) written disclosure of treatment policies and any restrictions or limitations on health services, including but not limited to physician services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologicals, and radiological examinations; and
(c) written notice that the enrollee may receive from another provider those medicaid-covered services that are not provided by the managed health care entity but that are the financial responsibility of the entity.
(6) The entity shall provide that enrollees within its system will be informed of the full panel of health care providers. Contracts for the provision of services beyond 125 miles from the borders of Montana may not be entered into if services of comparable cost and quality are available within the state of Montana.
(7) The entity may not discriminate in its enrollment or disenrollment practices among recipients of medical services or program enrollees based on health status.
(8) For purposes of participation in the medicaid program, the entity shall comply with quality assurance and utilization review requirements established in Title 33, chapter 36, and by the department by rule.
(9) The entity shall require that each provider meets the standards for accessibility and quality of care established by law. The department shall prepare an annual report regarding the effectiveness of the standards on ensuring access and quality of care to enrollees.
(10) The entity shall maintain, retain, and make available to the department records, data, and information, in a uniform manner determined by the department, that are:
(a) sufficient for the department, the legislative auditor's office, and the state auditor's office to monitor utilization, accessibility, and quality of care; and
(b) consistent with accepted practices in the health care industry.
(11) Except for health care providers who are prepaid, the entity shall pay all approved claims for covered services that are correctly completed and submitted to the entity within 30 days after receipt of the claim or receipt of the appropriate capitation payment or payments by the entity from the state for the month in which the services included on the claim were rendered, whichever is later. If payment is not made or mailed to the provider by the entity by the due date under this subsection, an interest penalty of 1% of any amount unpaid must be added for each month or fraction of a month after the due date until final payment is made. This part does not prohibit managed health care entities and health care providers from mutually agreeing to terms that require more timely payment.
(12) The entity shall seek cooperation with community-based programs provided by local health departments, such as the women, infants, and children food supplement program, childhood immunization programs, health education programs, case management programs, and health screening programs.
(13) The entity shall seek cooperation with community-based organizations, as defined by rule of the department, that may continue to operate under a contract with the department or a managed health care entity under this part to provide case management services to medicaid clients.
(14) A managed health care entity that provides written notice pursuant to subsection (5)(c) to an enrollee of medicaid-covered services available from another provider is responsible for payment for those services by another provider.
(15) A managed health care entity may not begin operation before the approval of any necessary federal waivers and the completion of the review of an application submitted to the department. The department may charge the applicant an application review fee for the department's actual cost of review of the application. The fee must be adopted by rule by the department. Fees collected by the department must be deposited in an account in the special revenue fund to be used by the department to defray the cost of application review.

Legislative History

En. Sec. 5, Ch. 502, L. 1995; amd. Sec. 8, Ch. 351, L. 2011.