DHS 10.43(2)(k)
(k) A provider network that meets the department's quantitative network adequacy standards.
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:
DHS 10.44(2)(e)1.L.
L. Education and vocational activities, including any needs for job development, job modifications, and ongoing support on the job.
DHS 10.44(2)(e)2.
2. Long-term care outcomes that are consistent with the values and preferences of the enrollee in at least the following areas:
DHS 10.44(2)(e)2.c.
c. Self-determination of daily routine, services, activities and living situation.
DHS 10.44(2)(f)
(f) The CMO, in partnership with the enrollee, shall develop an individual service plan for each enrollee, with the full participation of the enrollee and any family members or other representatives that the enrollee wishes to participate. The CMO shall provide support, as needed, to enable the enrollee, family members or other representatives to make informed service plan decisions, and for the enrollee to participate as a full partner in the entire assessment and individual service plan development process. The service plan shall meet all of the following conditions:
DHS 10.44(2)(f)1.
1. Reasonably and effectively addresses all of the long-term care needs and utilizes all enrollee strengths and informal supports identified in the comprehensive assessment under par.
(e) 1. DHS 10.44(2)(f)2.
2. Reasonably and effectively addresses all of the enrollee's long-term care outcomes identified in the comprehensive assessment under par.
(e) 2. and assists the enrollee to be as self-reliant and autonomous as possible and desired by the enrollee.
DHS 10.44(2)(f)3.
3. Is cost-effective compared to alternative services or supports that could meet the same needs and achieve similar outcomes.
DHS 10.44(2)(f)5.
5. If the enrollee and the CMO do not agree on a service plan, provide a method for the enrollee to file a grievance under s.
DHS 10.53, request department review under s.
DHS 10.54, or request a fair hearing under s.
DHS 10.55. Pending the outcome of the grievance, review or fair hearing, the CMO shall offer its service plan for the enrollee, continue negotiating with the enrollee and document that the service plan meets all of the following conditions:
DHS 10.44(2)(f)5.b.
b. Would not have a significant, long-term negative impact on the enrollee's long-term care outcomes identified under par.
(e) 2. DHS 10.44(2)(f)5.c.
c. Balances the needs and outcomes identified by the comprehensive assessment with reasonable cost, immediate availability of services and ability of the CMO to develop alternative services and living arrangements.
DHS 10.44(2)(f)5.d.
d. Was developed after active negotiation between the CMO and the enrollee, during which the CMO offered to find or develop alternatives that would be more acceptable to both parties.
DHS 10.44(2)(g)
(g) The CMO shall reassess each enrollee's needs and strengths as specified under par.
(e) 1. and long-term care outcomes as specified under par.
(e) 2. and adjust the individual service plan based on the findings of the re-assessment, as specified in par.
(j) 5. DHS 10.44(2)(h)
(h) The CMO shall provide, arrange, coordinate and monitor services as required by its contract with the department and as specified in the enrollee's individual service plan. The CMO shall provide opportunity for each enrollee to be involved, to the extent that he or she is able and willing, in all of the following:
DHS 10.44(2)(h)1.
1. The selection of service providers from within the CMO's network of providers.
DHS 10.44(2)(h)2.
2. The recruiting, interviewing, hiring, training and supervision of individuals providing personal care and household assistance in the enrollee's home.
DHS 10.44(2)(i)
(i) The CMO shall provide assistance to enrollees in arranging for and coordinating services that are outside the direct responsibility of the CMO.
DHS 10.44(2)(j)
(j) The CMO shall meet timeliness standards as specified in its contract with the department, that shall include all of the following:
DHS 10.44(2)(j)1.
1. Immediately upon enrollment, the CMO shall provide services to preserve the health and safety of the enrollee. Within 5 days of enrollment, the CMO shall develop and implement an initial service plan based on information received from the resource center and the CMO's initial assessment of the enrollee's needs.
DHS 10.44(2)(j)2.
2. The CMO shall complete a comprehensive assessment, as specified under par.
(e) not later than 30 days after enrollment.
DHS 10.44(2)(j)3.
3. Within 60 days of enrollment, the CMO shall, jointly with the enrollee and any other individual identified by the enrollee, develop an individualized service plan as specified under par.
(f).
DHS 10.44(2)(j)4.
4. The CMO shall provide services and support items in accordance with the time frames specified in each enrollee's individualized service plan.
DHS 10.44(2)(j)5.
5. The CMO shall review each enrollee's service plan and adjust services if indicated by the review, as follows:
DHS 10.44(2)(j)5.a.
a. Whenever a significant change occurs in the enrollee's health, functional capacity or other circumstances.
DHS 10.44(2)(j)5.b.
b. When requested by the enrollee, the enrollee's representative, the enrollee's primary medical provider, or an agency providing services to the enrollee.
DHS 10.44(2)(j)5.c.
c. As often as necessary in relation to the stability of the enrollee's health and circumstances, but not less than every 180 days.
DHS 10.44(2)(j)6.
6. The CMO shall provide required reports in a timely manner as specified in its contract with the department.
DHS 10.44(3)
(3)
Service monitoring. A CMO shall do all the following:
DHS 10.44(3)(a)
(a) Develop and implement standards for CMO service provider qualifications and written procedures and protocols for assessing whether providers meet the standards. Provider qualification standards established by a CMO shall meet or exceed standards that are specified in its contract with the department.
DHS 10.44(3)(b)
(b) Develop and implement written procedures and protocols that assure that services furnished are consistent with the needs and strengths identified under sub.
(2) (e) 1., the long-term care outcomes identified under sub.
(2) (e) 2. and the individual service plan under sub.
(2) (f) for each enrollee.
DHS 10.44(3)(c)
(c) Develop and implement written procedures and protocols that assure that enrollee problems related to services are detected and promptly addressed.
DHS 10.44(3)(d)
(d) Maintain a process to consider an enrollee's request to receive services from a provider who does not have an agreement with the CMO for providing services to the CMO's enrollees. The CMO shall arrange for services with non-CMO providers if the enrollee's request is authorized by the CMO. Instances where the enrollee's request for a non-CMO provider is warranted include all of the following:
DHS 10.44(3)(d)1.
1. When the CMO does not have the capacity to meet the identified needs of its enrollees.
DHS 10.44(3)(d)2.
2. When the CMO does not have the specialized expertise, specialized knowledge or appropriate cultural diversity in its network of providers.
DHS 10.44(3)(d)4.
4. When transportation or physical access to the CMO providers causes an undue hardship to the enrollee.
DHS 10.44(3)(e)
(e) Offer each enrollee the opportunity to participate in the monitoring and improvement of services in the enrollee's care plan.
DHS 10.44(4)
(4)
Internal quality assurance and quality improvement. The CMO shall implement an internal quality assurance and quality improvement program that [meets] the requirements of its contract with the department. As part of the program, the CMO shall do all of the following:
DHS 10.44(4)(a)
(a) Measure CMO performance, using standard measures as required in its contract with the department, and report its findings on these measurements to the department.
DHS 10.44(4)(b)
(b) Demonstrate, through the standard measures agreed to in its contract with the department, that the CMO meets or exceeds minimum performance standards and that the CMO is continuously improving its performance in achieving enrollee outcomes in all of the areas specified in sub.
(2) (e) 2. DHS 10.44(4)(c)
(c) Comply with the standards for quality of services included in the CMO's contract with the department in all of the following areas:
DHS 10.44(4)(c)1.
1. Availability of services and adequacy of the CMO's provider network.
