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.