Ins 57.05(6)(c)(c) The method of payment.
Ins 57.05(6)(d)(d) The duration of the contract.
Ins 57.05(6)(e)(e) Any provisions for modifying, terminating or renewing the contract.
Ins 57.05(7)(7)Financial projections. A summary of all of the following:
Ins 57.05(7)(a)(a) Current and projected enrollment.
Ins 57.05(7)(b)(b) Income from capitation payments.
Ins 57.05(7)(c)(c) Other income.
Ins 57.05(7)(d)(d) Expenses associated with providing services to enrollees. A budget narrative that accompanies any projections related to care management utilization shall be provided. The narrative will identify assumed staff-to-member ratios, by type of staff; historical trends and projections regarding care management utilization; explanations regarding any major changes; and unit cost trends for each time period and target group.
Ins 57.05(7)(e)(e) Administrative and other costs.
Ins 57.05(7)(f)(f) The estimated break even point if a loss is being projected.
Ins 57.05(7)(g)(g) A summary of the assumptions made in developing projected operating results.
Ins 57.05(8)(8)Strengths, Weaknesses, Opportunities and Threats analysis. An analysis of the CMO’s strengths, weaknesses, opportunities and threats, a description of the major challenges the CMO faces, both internal and external to the organization, in providing services to each target group, and the strategies it is employing, or plans to employ, to address those challenges.
Ins 57.05(9)(9)Financial guarantees. A summary of all financial guarantees by providers, sponsors, affiliates or parents within a holding company system, or any other guarantees which are intended to ensure the financial success of the care management organization. These include hold harmless agreements by providers, stop loss insurance, or other guarantees.
Ins 57.05(10)(10)Business plan requirements of the department. The business plan filed with the department pursuant to provisions in the family care contract is acceptable for the purposes of this section.
Ins 57.05 HistoryHistory: EmR0927: emerg. cr. eff. 10-10-09; CR 09-093: cr. Register May 2010 No. 653, eff. 6-1-10.
Ins 57.06Ins 57.06Changes in the business plan. A care management organization shall file a written report of any proposed substantial change in its business plan. The care management organization shall file the report at least 30 days prior to the effective date of the change. The office, after consulting with the department, may disapprove the change. The care management organization may not enter into any transaction, contract, amendment to a transaction or contract or take action or make any omission that is a substantial change in the care management organization’s business plan prior to the effective date of the change or if the change is disapproved. Substantial changes include changes in articles and bylaws, organization type, geographical service areas, provider agreements, provider availability, plan administration, financial projections and guarantees and any other change that might affect the financial solvency of the organization. Any transaction or series of transactions that exceed the lesser of 5% of the care management organization’s assets or 10% of net assets as of December 31 of the immediately preceding calendar year shall be deemed material. Any changes in the items listed in s. Ins 9.05 (3) shall be filed under this section.
Ins 57.06 HistoryHistory: EmR0927: emerg. cr. eff. 10-10-09; CR 09-093: cr. Register May 2010 No. 653, eff. 6-1-10.
Ins 57.07Ins 57.07Copies of provider agreements.
Ins 57.07(1)(1)Notwithstanding any claim of trade secret or proprietary information, all care management organizations shall, upon request, from the commissioner, make available to the commissioner all executed copies of any provider agreements between the care management organization and intermediate entities or individual providers. Any party to a provider agreement may assert that a portion of the contracts contain trade secrets, and the commissioner may withhold that portion to the extent it may be withheld under s. Ins 6.13.
Ins 57.07(2)(2)All care management organizations shall file with the commissioner a list of providers executing a standard contract and a copy of the form of the contract may be filed instead of copies of the executed contracts.
Ins 57.07 HistoryHistory: EmR0927: emerg. cr. eff. 10-10-09; CR 09-093: cr. Register May 2010 No. 653, eff. 6-1-10.
Ins 57.10Ins 57.10Acquisition of control of or merger with a care management organization.
Ins 57.10(1)(1)Filing requirements.
Ins 57.10(1)(a)(a) No person other than the care management organization may enter into an agreement to merge with or otherwise to acquire or attempt to acquire control of a care management organization or any person having control of a care management organization unless all of the following are complied with:
Ins 57.10(1)(a)1.1. The person first files the information required under sub. (2) with the commissioner and sends a copy of the information to the care management organization; and
Ins 57.10(1)(a)2.2. The offer, request, invitation, agreement or acquisition has been approved by the commissioner.
Ins 57.10(1)(b)(b) For purposes of this section “care management organization” includes any person having control of a care management organization.
Ins 57.10(2)(2)Content of statement. A person required to file under sub. (1) shall file the following information not less than 30 days after the care management organization signs a letter of intent, using information substantially similar to that contained in form A in Appendix 1 to this chapter, in a sworn statement by an official of the care management organization:
Ins 57.10(2)(a)(a) For each acquiring person: