Montana Code 33-36-102. Purpose
33-36-102. Purpose. The purpose and intent of this chapter are to:
Terms Used In Montana Code 33-36-102
- 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 care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. 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
- Network: means the group of participating providers that provides health care services to a managed care plan. See Montana Code 33-36-103
- Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
- provider: means a health care professional or a facility. 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 assurance: means quality assessment and quality improvement. See Montana Code 33-36-103
- 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
(1)establish standards for the creation and maintenance of networks by health carriers offering managed care plans and to ensure the adequacy, accessibility, and quality of health care services offered under a managed care plan by establishing requirements for written agreements between health carriers offering managed care plans and participating providers regarding the standards, terms, and provisions under which the participating provider will provide services to covered persons;
(2)provide for the implementation of state network adequacy and quality assurance standards in administrative rules, provide for monitoring compliance with those standards, and provide a mechanism for detecting and reporting violations of those standards to the commissioner;
(3)establish minimum criteria for the quality assessment activities of a health carrier issuing a closed plan or a combination plan and to require that minimum state quality assessment criteria be adopted by rule;
(4)enable health carriers to evaluate, maintain, and improve the quality of health care services provided to covered persons; and
(5)provide a streamlined and simplified process by which managed care network adequacy and quality assurance programs may be monitored for compliance through efforts by the commissioner. It is not the purpose or intent of this chapter to apply quality assurance standards applicable to medicaid or medicare to managed care plans regulated pursuant to this chapter or to create or require the creation of quality assurance programs that are as comprehensive as quality assurance programs applicable to medicaid or medicare.