Montana Code 53-6-1311. Medicaid program reforms
53-6-1311. (Temporary) Medicaid program reforms. (1) To ensure that the Montana medicaid program is administered efficiently and effectively, the department shall strengthen existing programs that manage the way members obtain approval for medical services and shall establish additional programs designed to reduce costs and improve medical outcomes. The efforts may include but are not limited to:
Terms Used In Montana Code 53-6-1311
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1303
- Fraud: Intentional deception resulting in injury to another.
- Member: means an individual enrolled in the Montana medicaid program pursuant to 53-6-131 or receiving medicaid-funded services pursuant to 53-6-1304. See Montana Code 53-6-1303
- 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
(a)establishing by rule requirements designed to strengthen the relationship between physicians and members enrolled in existing primary care case management programs;
(b)strengthening data-sharing arrangements with providers to reduce inappropriate use of emergency room services and overuse of other services;
(c)expanding to additional members any existing programs in which case managers and providers work with members with high-risk medical conditions to provide preventive care and advice and to make referrals for medical services;
(d)establishing, within existing funds, one or more pilot programs to improve the health of members, including but not limited to efforts to increase pain management, decrease emergency department overuse, and prevent drug or alcohol addiction or abuse;
(e)reviewing existing primary care case management programs to evaluate and improve their effectiveness; and
(f)engaging members with chronic or other medical or behavioral health conditions in coordinated care models that more closely monitor and manage a member‘s health to reduce costs or improve medical outcomes. These coordinated care models may include but are not limited to:
(i)patient-centered medical homes;
(ii)accountable care organizations;
(iii)managed care organizations as defined in 42 C.F.R. § 438.2;
(iv)health improvement programs;
(v)health homes for behavioral health or other chronic conditions; and
(vi)changes to current service delivery methods.
(2)The department shall work to reduce fraud, waste, and abuse in the medicaid program before, during, and after enrollment by enhancing technology system support to provide knowledge-based authentication for verifying the identity and financial status of individuals seeking benefits, including the use of public records to confirm identity and flag changes in demographics.
(3)The department may ask a third-party administrator under contract with the department to assist in efforts undertaken pursuant to subsections (1) and (2) when the activity can appropriately be handled by a third-party administrator.
(4)A care coordination entity used to deliver medicaid services shall meet all state standards for operation, including but not limited to solvency, consumer protection, nondiscrimination, network adequacy, care model design, and fraud and abuse standards. (Terminates June 30, 2025–secs. 38, 48, Ch. 415, L. 2019.)