DHS 10.46(5)(a) (a) CMO cost-effectiveness in meeting member needs within available resources.

DHS 10.46(5)(b) (b) CMO financial condition.

DHS 10.46(6) (6) Cost of services. The department shall measure the cost of all department-funded health care services received by CMO enrollees.

DHS 10.46 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (f) Register November 2004 No. 587, eff. 12-1-04.

subch. V of ch. DHS 10 Subchapter V — Protection of Applicant, Eligible Person and Enrollee Rights

DHS 10.51 DHS 10.51 Client rights. Clients shall have the rights in family care that are outlined in the applicant information materials they receive when contacting a resource center and in the member handbook they receive prior to enrollment in a care management organization. The department shall review and approve the statement of client rights and responsibilities in each resource center’s applicant information materials and in each CMO’s member handbook. Client rights shall, at a minimum, include an explanation of client rights in the following areas:

DHS 10.51(1) (1) Rights of clients. Clients have the right to all of the following:

DHS 10.51(1)(a) (a) Freedom from unlawful discrimination in applying for or receiving the family care benefit.

DHS 10.51(1)(b) (b) Accuracy and confidentiality of client information.

DHS 10.51(1)(c) (c) Prompt eligibility, entitlement and cost-sharing decisions and assistance.

DHS 10.51(1)(d) (d) Access to personal, program and service system information.

DHS 10.51(1)(e) (e) Choice to enroll in a CMO, if eligible, and to disenroll at any time.

DHS 10.51(1)(f) (f) Information about and access to all services of resource centers and CMOs within standards established under this chapter to the extent that the client is eligible for such services.

DHS 10.51(1)(g) (g) Support for all clients in understanding their rights and responsibilities related to family care, including due process procedures, and in providing their comments about resource centers, CMOs and services, including through grievances, appeals and requests for department review and fair hearings. Resource centers, CMOs and county agencies under contract with the department shall assist clients to identify all rights to which they are entitled and, if multiple grievance, review or fair hearing mechanisms are available, which mechanism will best meet client needs.

DHS 10.51(1)(h) (h) Support for all clients in the exercise of any rights and available grievance and appeal procedures beyond those specified in this chapter.

DHS 10.51 Note Note: Examples of other rights and procedures available to clients include those afforded to persons who receive treatment or services for developmental disability, mental illness or substance abuse under ch. 51, Stats. and ch. DHS 94, and those afforded to persons who reside in a nursing home, community-based residential facility, adult family home or residential care apartment complex, or who receive services from a home health agency under statutes and rules of those programs.

DHS 10.51(2) (2) Rights of enrollees. Enrollees have the right to all of the following:

DHS 10.51(2)(a) (a) Support from the CMO in all of the following:

DHS 10.51(2)(a)1. 1. Self-identifying long-term care needs and appropriate family care outcomes.

DHS 10.51(2)(a)2. 2. Securing information regarding all services and supports potentially available to the enrollee through the family care benefit.

DHS 10.51(2)(a)3. 3. Actively participating in planning individualized services and making reasonable service and provider choices for achieving identified outcomes.

DHS 10.51(2)(b) (b) Receipt of services identified in the individualized service plan.

DHS 10.51(3) (3) Application of other rules and regulations. Nothing in this chapter shall limit or adversely affect the rights afforded to clients in accordance with other state or federal laws or regulations. To the extent that provisions in this chapter differ from provisions affording a client rights under other state or federal laws or regulations, the provision that does most to promote the rights of the client shall be controlling.

DHS 10.51 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (g) and (2) (b), cr. (1) (h) and (3), Register November 2004 No. 587, eff. 12-1-04.

DHS 10.52 DHS 10.52 Required notifications.

DHS 10.52(1) (1) Notification of general client rights and responsibilities. Each resource center, county agency and CMO shall provide clients with written notification of their rights and responsibilities in accordance with timelines and other requirements established in its contract with the department in every instance in which:

DHS 10.52(1)(a) (a) The client applies for the family care benefit and is initially counseled by a resource center about the family care benefit or enrollment in a specific care management organization.

DHS 10.52(1)(b) (b) The client enrolls in a care management organization.

DHS 10.52(2) (2) Notification of eligibility or entitlement. Every applicant for the family care benefit shall be notified in writing of decisions regarding eligibility, entitlement and cost sharing requirements as required under s. DHS 10.31 (6) (b).