Montana Code 33-36-302. Standards for health carrier quality assessment programs
33-36-302. Standards for health carrier quality assessment programs. A health carrier that issues a closed plan or a combination plan shall adopt and use infrastructure and disclosure systems sufficient to accurately measure the quality of health care services provided to covered persons on a regular basis and appropriate to the types of plans offered by the health carrier. To comply with this requirement, a health carrier shall:
Terms Used In Montana Code 33-36-302
- Closed plan: means a managed care plan that requires covered persons to use only participating providers under the terms of the managed care plan. See Montana Code 33-36-103
- Combination plan: means an open plan with a closed component. See Montana Code 33-36-103
- Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Montana Code 33-36-103
- Health carrier: means an entity subject to the insurance laws and rules of this state that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a disability insurer, health maintenance organization, or health service corporation or another entity providing a health benefit plan. See Montana Code 33-36-103
- Participating provider: means a provider who, under a contract with a health carrier or with the health carrier's contractor, subcontractor, or intermediary, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier. See Montana Code 33-36-103
- provider: means a health care professional or a facility. See Montana Code 33-36-103
- Quality assessment: means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations. See Montana Code 33-36-103
(1)establish and use a system designed to assess the quality of health care provided to covered persons and appropriate to the types of plans offered by the health carrier. The system must include systematic collection, analysis, and reporting of relevant data.
(2)communicate in a timely fashion its findings concerning the quality of health care to regulatory agencies, providers, and consumers as provided in 33-36-304;
(3)report to the appropriate professional or occupational licensing board provided in Title 37 any persistent pattern of problematic care provided by a participating provider that is sufficient to cause the health carrier to terminate or suspend a contractual arrangement with the participating provider; and
(4)file a written description of the quality assessment program and any subsequent material changes with the commissioner in a format that must be prescribed by rules of the commissioner. The description must include a signed certification by a corporate officer of the health carrier that the health carrier’s quality assessment program meets the requirements of this part.