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.
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.
If an organization applying to operate a CMO meets standards for certification under s. 46.284 (2)
, 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:
A regional long-term care advisory committee established under s. 46.2825 (1)
, Stats., has advised the department about the organization and its ability to provide the family care benefit, as provided in s. 46.2825 (2) (a)
, Stats., and the department has considered that advice.
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.
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.
Before January 1, 2003, the organization is a county or a family care district, unless any of the following applies:
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.
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)
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:
The county or family care district fails to meet requirements of s. DHS 10.43
or the requirements under its contract with the department.
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.
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)
, 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.
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:
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 all of the following:
The regional long-term care advisory committee appointed under s. 46.2825 (1)
, Stats., serving the area in which an organization operates, or proposes to operate, a resource center.
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.
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.
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
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
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)
, Stats., and all of the following standards:
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:
A sufficient number of qualified and competent staff to meet case management standards under s. DHS 10.44
Thorough knowledge of local long-term care and other community resources.
Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into individual service plans.
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.
Mechanisms to coordinate services internally and with services available from community organizations and other social programs.
Thorough knowledge of employment opportunities and barriers for the organization's target population.
Thorough knowledge of methods for promoting and supporting the use of mechanisms under which individuals direct and manage their own service funding.
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:
Agreements with providers who can provide all required services in the family care benefit.
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.
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.
The ability to provide services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.
The ability to provide an appropriate range of residential and day services that are geographically accessible to proposed enrollees' homes, families, guardians or friends.
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.
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.
The ability to develop residential options that meet individual needs and desired outcomes of its enrollees.
Mechanisms for assuring that all service providers meet required licensure, accreditation, or other quality assurance standards.
Mechanisms for assuring that any service provider dissatisfied with the CMO's contract requirements shall have the opportunity to request review by the department.
Certification as a medical assistance provider.
The organization shall be certified by the department under s. DHS 105.47
The organization shall demonstrate that it has the organizational capacity to operate a CMO, including all of the following:
Financial solvency and stability and the ability to assume the level of financial risk required under the contract.
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.
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.
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)
Standards for performance by CMOs. DHS 10.44(1)(1)
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.
Case management standards.
The CMO shall provide case management services that meet all of the following standards:
The CMO's case management personnel shall meet staff qualification standards contained in its contract with the department.
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.
The CMO shall employ or contract with a sufficient number of case management personnel to ensure that enrollees' services continue to meet their needs.
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:
An initial assessment sufficient to provide information necessary to establish an individual budget amount and to identify health and safety issues.
Monitoring the enrollee's use of the individual budget amount for purchase of services or support items.
Monitoring to ensure the enrollee reports service utilization adequately to allow the CMO to meet federal and state reporting requirements.
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:
The needs and strengths of each enrollee in at least the following areas:
Education and vocational activities, including any needs for job development, job modifications, and ongoing support on the job.
Long-term care outcomes that are consistent with the values and preferences of the enrollee in at least the following areas:
Self-determination of daily routine, services, activities and living situation.