DHS 10.42(2)(am)2.a.a. Case management/care coordination/service planning.
DHS 10.42(2)(am)2.b.b. Quality improvement.
DHS 10.42(2)(am)2.c.c. Utilization review.
DHS 10.42(2)(am)3.3. Financial management, including all of the following:
DHS 10.42(2)(am)3.a.a. Financial reporting and monitoring.
DHS 10.42(2)(am)3.b.b. Financial solvency.
DHS 10.42(2)(am)4.4. Systems management, including all of the following:
DHS 10.42(2)(am)4.a.a. Claims management.
DHS 10.42(2)(am)4.b.b. Encounter data and enrollment information management.
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)(c)(c) The department has determined 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 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)1.1. Paragraph (d) 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 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 NoteNote: 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(5)(a)(a) Suspension of new enrollment.
DHS 10.42(5)(b)(b) Enrollment reductions.
DHS 10.42(5)(c)(c) Withholding or reduction of payments.
DHS 10.42(5)(d)(d) Imposition of damages.
DHS 10.42(5)(e)(e) Appointment of temporary management of the CMO.
DHS 10.42(5)(f)(f) Contract termination.
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(9)(9)Prior to receiving funds to provide the family care benefit, an organization shall agree to the terms of the standard CMO contract.