Montana Code 33-36-303. Standards for health carrier quality improvement programs
33-36-303. Standards for health carrier quality improvement programs. A health carrier that issues a closed plan or a combination plan shall, in addition to complying with 33-36-302, adopt and use systems and methods necessary to improve the quality of health care provided in the health carrier’s managed care plan as indicated by the health carrier’s quality assessment program and as required by this section. To comply with this requirement, a health carrier subject to this section shall:
Terms Used In Montana Code 33-36-303
- 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 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
- Managed care plan: means a health benefit plan that either requires or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by a health carrier, but not preferred provider organizations or other provider networks operated in a fee-for-service indemnity environment. 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
- Quality improvement: means an effort to improve the processes and outcomes related to the provision of health care services within a health plan. See Montana Code 33-36-103
(1)establish an internal system capable of identifying opportunities to improve care;
(2)use the findings generated by the system required by subsection (1) to work on a continuing basis with participating providers and other staff within the closed plan or closed component to improve the health care delivered to covered persons; and
(3)consistent with this part, adopt and use a program for measuring, assessing and improving the outcomes of health care as identified in the health carrier’s quality improvement program plan and provide at the commissioner’s request a current quality improvement program plan. The quality improvement program plan must:
(a)implement improvement strategies in response to quality assessment findings that indicate improvement is needed; and
(b)evaluate, not less than annually, the effectiveness of the strategies implemented pursuant to subsection (3)(a).