53-6-1305. (Temporary) 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:

Terms Used In Montana Code 53-6-1305

  • act: means the Montana Health and Economic Livelihood Partnership Act provided for in Title 39, chapter 12, and this part. See Montana Code 53-6-1303
  • Contract: A legal written agreement that becomes binding when signed.
  • Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1303
  • Member: means an individual enrolled in the Montana medicaid program pursuant to 53-6-131 or receiving medicaid-funded services pursuant to 53-6-1304. See Montana Code 53-6-1303
  • State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201

(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. (Terminates June 30, 2025–secs. 38, 48, Ch. 415, L. 2019.)

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