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

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

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.