DHS 10.37(2)
(2)
Case management available for purchase. A care management organization shall offer case management services, at rates approved by the department, to private pay individuals who wish to purchase the services. A private pay individual may purchase from the CMO any types and amounts of case management. The types and amounts of case management and the cost of the services shall be specified in a written agreement signed by the authorized representative of the CMO and the individual purchasing the service or the person's authorized representative.
DHS 10.37(3)(a)
(a) A private pay individual may not enroll in a care management organization, but, subject to pars.
(b) and
(c), may purchase services other than case management services, on a fee-for-service basis, from a care management organization.
DHS 10.37(3)(b)
(b) An individual who meets the definition under sub.
(1) (b) 1. may purchase any service that the CMO provides directly and offers to the general public, at prices normally charged to the public.
DHS 10.37(3)(c)
(c) An individual who meets the definition under sub.
(1) (b) 2. or
3. may purchase any service purchased or provided by the CMO for its members.
DHS 10.37 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (1) (a)
Register November 2004 No. 587, eff. 12-1-04.
DHS 10.41(1)(1)
Enrollment required. The family care benefit is available to eligible persons only through enrollment in a care management organization (CMO) under contract with the department.
DHS 10.41(2)
(2)
Services. Services provided under the family care benefit shall be determined through individual assessment of enrollee needs and values and detailed in an individual service plan unique to each enrollee. As appropriate to its target population and as specified in the department's contract, each CMO shall have available at least the services and support items covered under the home and community-based waivers under
42 USC 1396n (c) and ss.
46.275,
46.277, and
46.278, Stats., the long-term support community options program under s.
46.27, Stats., and specified services and support items under the state's plan for medical assistance. In addition, a CMO may provide other services that substitute for or augment the specified services if these services are cost-effective and meet the needs of enrollees as identified through the individual assessment and service plan. When providing applicable services, CMOs shall comply with EVV requirements.
DHS 10.41 Note
Note: The services that typically will be required to be available include adaptive aids; adult day care; assessment and case planning; case management; communication aids and interpreter services; counseling and therapeutic resources; daily living skills training; day services and treatment; home health services; home modification; home delivered and congregate meal services; nursing services; nursing home services, including care in an intermediate care facility for individuals with intellectual disabilities or in an institution for mental diseases; personal care services; personal emergency response system services; prevocational services; protective payment and guardianship services; residential services in an RCAC, CBRF or AFH; respite care; durable medical equipment and specialized medical supplies; outpatient speech; physical and occupational therapy; supported employment; supportive home care; transportation services; mental health and alcohol or other drug abuse services; and community support program services.
DHS 10.41(3)
(3)
Payment mechanisms. Payment to a care management organization shall be on a per enrollee per month basis. Any contractual agreements for shared financial risk between the department and a CMO shall meet applicable federal requirements.
DHS 10.41 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 22-026: am. (2)
Register May 2023 No. 809, eff. 6-1-23;
EmR2306: emerg. am. (2), eff. 5-1-23; CR 23-045: am. (2) Register January 2024 No. 817, eff. 2-1-24; correction in (2) made under s. 35.17, Stats., Register January 2024 No. 817. DHS 10.42
DHS 10.42
Certification and contracting. DHS 10.42(1)(1)
No entity may receive payment of funds for the family care benefit as a care management organization unless it is certified by the department as meeting all of the requirements of s.
46.284, Stats., and this chapter and is under contract with the department.
DHS 10.42(2)(a)(a) To obtain and retain certification, an organization shall submit all information and documentation required by the department, in a format prescribed by the department, including comments it has obtained from each regional long-term care advisory committee in the area it proposes to serve. The department shall review and make a determination on the application within 90 calendar days of receipt of a complete application containing complete and accurate supporting documentation that the organization meets the standards under s.
DHS 10.43. The department may conduct any necessary investigation to verify that the information submitted by the organization is accurate. The organization shall consent to disclosure by any third party of information the department determines is necessary to review the application.
DHS 10.42(2)(b)
(b) If the department denies CMO certification for the organization, the department shall provide written notice to the organization that clearly states the reasons for the denial and describes the manner by which the organization may appeal the department's decision.
DHS 10.42(3)
(3) If an organization applying to operate a CMO meets standards for certification under s.
46.284 (2) and
(3), Stats., and s.
DHS 10.43, the department shall certify the organization as meeting the requirements. Certification by the department does not bind the department to contracting with the organization to operate a CMO. The department may contract with a certified organization to operate a CMO only if all of the following apply:
DHS 10.42(3)(b)
(b) The regional long-term care advisory committee and individuals from the local target population that the organization proposes to serve have assisted the department in its review and evaluation of all applications of organizations proposing to serve a geographic area.
DHS 10.42(3)(c)
(c) The department has determined, after considering the advice of the regional long-term care advisory committee for the geographic area, that the organization's services are needed to provide sufficient access to the family care benefit for eligible individuals.
DHS 10.42(3)(d)
(d) Before January 1, 2003, the organization is a county or a family care district, unless any of the following applies:
DHS 10.42(3)(d)1.
1. The county and the regional long-term care advisory committee agree in writing that at least one additional care management organization is necessary or desirable.
DHS 10.42(3)(d)2.
2. The governing body of a tribe or band or the Great Lakes inter–tribal council, inc., elects to operate a care management organization within the area and is certified under sub.
(2).
DHS 10.42(3)(e)
(e) After December 31, 2002, and before January 1, 2004, the organization is a county or a family care district unless any of the following applies:
DHS 10.42(3)(e)2.
2. The county or family care district fails to meet requirements of s.
DHS 10.43 or
10.44 or the requirements under its contract with the department.
DHS 10.42(3)(e)3.
3. The department determines that the county or family care district does not have the capacity to serve all county residents who are entitled to the family care benefit in the client group or groups that the county or family care district serves and cannot develop the capacity. If this subd.
3. applies, the department may contract with an organization in addition to the county.
DHS 10.42(4)
(4) After December 31, 2003, the department may contract with counties, family care districts, the governing body of a tribe or band or the Great Lakes inter–tribal council, inc., or under a joint application of any of these, or with a private organization that has no significant connection to an entity that operates a resource center. Proposals for contracts under this subsection shall be solicited under a competitive sealed proposal process under s.
16.75 (2m), Stats., and, after consulting with the regional long-term care advisory committee for the county or counties, the department shall evaluate the proposals primarily as to the quality of care that is proposed to be provided and certify those applicants that meet the requirements specified in s.
46.284 (2) and
(3), Stats., and s.
DHS 10.43. The department may select certified applicants for contract and contract with the selected applicants.
DHS 10.42 Note
Note: Until July 1, 2001, the Wisconsin Legislature has authorized the Department to establish Family Care pilots in areas of the state in which not more than 29% of the state's eligible population lives. After that date, if specifically authorized and funded by the Legislature, the Department may contract with additional entities certified as meeting requirements for a CMO. The Department is required to submit, prior to November 1, 2000, a report to the Governor that describes the implementation and outcomes of the pilots and makes recommendations about further development of Family Care.
DHS 10.42(5)
(5) The department's contracts with CMOs shall specify a range of remedies that may be taken in the event of noncompliance by the CMO with contract requirements. The remedies may include the following:
DHS 10.42(6)
(6) Except as provided in this subsection, the department shall use standard contract provisions for contracting with CMOs. The provisions of the standard contract shall comply with all applicable state and federal laws and may be modified only in accordance with those laws and after consideration of the advice of the secretary's council on long-term care.
DHS 10.42(7)
(7) The department shall annually provide to the members of the secretary's council on long-term care copies of the standard CMO contract the department proposes to use in the next contract period and seek the advice of the council regarding the contract's provisions. The department shall consider any recommendations of the council and may make revisions, as appropriate, based on those recommendations. If the department proposes to modify the terms of the standard contract, including adding or deleting provisions, in contracting with one or more organizations, the department shall seek the advice of the council and consider any recommendations of the council before making the modifications.
DHS 10.42(8)
(8) Whenever the department considers an application from an organization to be certified as meeting the standards for a CMO, the department shall provide a copy of the standard resource center contract to the regional long-term care advisory committee serving the area in which an organization operates, or proposes to operate, the CMO. If the department proposes to modify the contract, including adding or deleting provisions, the department shall seek the advice of the committee and consider any recommendations of the committee prior to signing the modified contract.
DHS 10.42(9)
(9) Prior to receiving funds to provide the family care benefit, an organization shall agree to the terms of the standard CMO contract.
DHS 10.42 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (6) (a) and (7)
Register November 2004 No. 587, eff. 12-1-04; corrections in (2) (a), (3) (a), (b), (c), (d) 1., (4), (6) (b) and (8) made under s.
13.92 (4) (b) 7., Stats.,
Register November 2009 No. 647;
CR 22-026: r. (3) (a), cons. (6) (intro.) and (a) and renum. to (6) and am., r. (6) (b)
Register May 2023 No. 809, eff. 6-1-23.
DHS 10.43
DHS 10.43
CMO certification standards. If an organization applies for a contract to operate a CMO, the department shall determine whether the organization meets the requirements of s.
46.284 (2) and
(3), Stats., and all of the following standards:
DHS 10.43(1)
(1)
Case management capability. Each organization applying to operate a CMO shall demonstrate to the department that it has expertise in determining and arranging for services and supports to meet the needs of its target population. Demonstration of this expertise includes evidence that the organization, a subcontractor, or both, has all of the following:
DHS 10.43(1)(a)
(a) A sufficient number of qualified and competent staff to meet case management standards under s.
DHS 10.44.
DHS 10.43(1)(b)
(b) Thorough knowledge of local long-term care and other community resources.
DHS 10.43(1)(c)
(c) Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into individual service plans.
DHS 10.43(1)(d)
(d) Strong linkages with systems and services that are not directly within the scope of the CMO's responsibility but that are important to the organization's target population, including primary and acute health care services, and the capacity to arrange for those services to be made available to its enrollees.
DHS 10.43(1)(e)
(e) Mechanisms to coordinate services internally and with services available from community organizations and other social programs.
DHS 10.43(1)(f)
(f) Thorough knowledge of employment opportunities and barriers for the organization's target population.
DHS 10.43(1)(g)
(g) Thorough knowledge of methods for promoting and supporting the use of mechanisms under which individuals direct and manage their own service funding.
DHS 10.43(2)
(2)
Adequate availability of providers. Each organization applying to operate a CMO shall demonstrate to the department that it has adequate availability of qualified providers with the expertise and ability to serve its target population in a timely manner. To demonstrate an adequate availability of qualified providers, an organization shall assure the department that it has all of the following:
DHS 10.43(2)(a)
(a) Agreements with providers who can provide all required services in the family care benefit.
DHS 10.43(2)(b)
(b) Appropriate provider connections to qualify providers, on a timely basis, as needed to directly reflect the specific needs and preferences of particular enrollees in its target population.
DHS 10.43(2)(c)
(c) Agreements with a broad array of providers representing diverse programmatic philosophies and cultural orientations to accommodate a variety of enrollee preferences and needs within its target population.
DHS 10.43(2)(d)
(d) The ability to provide services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.
DHS 10.43(2)(e)
(e) The ability to provide an appropriate range of residential and day services that are geographically accessible to proposed enrollees' homes, families, guardians or friends.
DHS 10.43(2)(f)
(f) Supported living arrangements of the types and sizes that meet its target population's preferences and needs and staff to coordinate residential placements who have shown capability in recruiting, establishing and facilitating placements with appropriate matching to enrollee needs.
DHS 10.43(2)(g)
(g) The ability to recruit, select and train new service providers, including in-home providers, in a timely fashion and a program designed to retain individual providers.
DHS 10.43(2)(h)
(h) The ability to develop residential options that meet individual needs and desired outcomes of its enrollees.
DHS 10.43(2)(i)
(i) Mechanisms for assuring that all service providers meet required licensure, accreditation, or other quality assurance standards.
DHS 10.43(2)(j)
(j) Mechanisms for assuring that any service provider dissatisfied with the CMO's contract requirements shall have the opportunity to request review by the department.
DHS 10.43(3)
(3)
Certification as a medical assistance provider. The organization shall be certified by the department under s.
DHS 105.47.
DHS 10.43(4)
(4)
Organizational capacity. The organization shall demonstrate that it has the organizational capacity to operate a CMO, including all of the following:
DHS 10.43(4)(a)
(a) Financial solvency and stability and the ability to assume the level of financial risk required under the contract.
DHS 10.43(4)(b)
(b) The ability to collect, monitor and analyze data for purposes of financial management and quality assurance and improvement and to provide that data to the department in the manner required under the contract.
DHS 10.43(4)(c)
(c) The capacity to support consumer employment, training and supervision of family members, friends and community members in carrying out services under the consumer's service plan.
DHS 10.43(5)
(5)
Grievance and appeal processes. The organization shall have a process for reviewing and resolving client grievances and appeals that meets the requirements under s.
DHS 10.53 (2).
DHS 10.44
DHS 10.44
Standards for performance by CMOs. DHS 10.44(1)(1)
Compliance. A care management organization shall comply with all applicable statutes, all of the standards in this subchapter and all requirements of its contract with the department.
DHS 10.44(2)
(2)
Case management standards. The CMO shall provide case management services that meet all of the following standards:
DHS 10.44(2)(a)
(a) The CMO's case management personnel shall meet staff qualification standards contained in its contract with the department.
DHS 10.44(2)(b)
(b) The CMO shall designate for each enrollee a case management team that includes at least a social service coordinator and a registered nurse. The CMO shall designate additional members of the team as necessary to ensure that expertise needed to assess and plan for meeting each member's needs is available.
DHS 10.44(2)(c)
(c) The CMO shall employ or contract with a sufficient number of case management personnel to ensure that enrollees' services continue to meet their needs.
DHS 10.44(2)(d)
(d) The CMO shall provide the opportunity for enrollees to manage service and support funds, as provided under sub.
(6). For enrollees managing service funding under sub.
(6), the role of the case management team in providing assistance in planning, arranging, managing and monitoring the enrollee's budget and services shall be negotiated between the enrollee and the case management team and at a level tailored to the enrollee's need and desire for assistance. At a minimum, the case management team's role shall include:
DHS 10.44(2)(d)1.
1. An initial assessment sufficient to provide information necessary to establish an individual budget amount and to identify health and safety issues.
DHS 10.44(2)(d)2.
2. Monitoring the enrollee's use of the individual budget amount for purchase of services or support items.
DHS 10.44(2)(d)4.
4. Monitoring to ensure the enrollee reports service utilization adequately to allow the CMO to meet federal and state reporting requirements.
DHS 10.44(2)(e)
(e) The CMO shall use assessment protocols that include a face-to-face interview with the enrollee and that comprehensively assess and identify all of the following:
DHS 10.44(2)(e)1.
1. The needs and strengths of each enrollee in at least the following areas:
