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(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(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: