1. (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:

   1. (a) establishing networks of health care providers;
   2. (b) paying claims submitted by health care providers;
   3. (c) collecting the premiums provided for in 53-6-1307;
   4. (d) coordinating care;
   5. (e) helping to administer the program; and
   6. (f) helping to administer the medicaid program reforms as specified in 53-6-1311.
2. (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. (3)

   1. (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.

   2. (b) If the department contracts with a third-party administrator, the department shall:

      1. (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;
      2. (ii) provide coverage for exempted individuals through the medical assistance program established in Title 53, chapter 6, part 1; and
      3. (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. (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.

History: En. Sec. 5, Ch. 368, L. 2015; amd. Sec. 33, Ch. 415, L. 2019.