53-6-1305. (Temporary -- effective on occurrence of contingency) Montana HELP Act program -- delivery of health care services -- third-party administrator -- rulemaking. (1) The department shall 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) The department shall determine the basic health care services to be provided through the arrangement with a 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 the 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, because the individuals:
(i) have exceptional health care needs, including but not limited to medical, mental health, or developmental conditions;
(ii) live in a geographical area, including an Indian reservation, for which the third-party administrator has been unable to make arrangements with sufficient health care providers to offer services to the individuals;
(iii) need continuity of care that would not be available or cost-effective through the arrangement with the third-party administrator; or
(iv) are otherwise exempt under federal law.
(b) The department shall:
(i) adopt rules establishing criteria for determining whether a member is exempt from receiving health care services through an arrangement with a third-party administrator; and
(ii) provide coverage for exempted individuals through the medical assistance program established in Title 53, chapter 6, part 1.
(4) For members participating in the arrangement with the third-party administrator, the department shall directly cover any service required under federal or state law that is not available through the arrangement with the third-party administrator.
(5) The department shall:
(a) seek federal authorization from the U.S. department of health and human services through a waiver authorized by 42 U.S.C. 1315 and other waivers or through other means, as may be necessary, to implement all of the provisions of Title 39, chapter 12, and this part; and
(b) implement access to the health care services in accordance with the requirements necessary to receive the federal medical assistance percentage provided for by 42 U.S.C. 1396d(y).
(6) The department may provide medicaid-funded services to members eligible pursuant to 53-6-1304 only upon federal approval of any necessary waivers. (Terminates June 30, 2019--sec. 28, Ch. 368, L. 2015.)
History: En. Sec. 5, Ch. 368, L. 2015.