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.
DHS 10.44(4)(c)5.
5. Protection of enrollee rights, including processes for protecting confidentiality and for acting on and resolving grievances and appeals.
DHS 10.44(4)(c)6.
6. Mechanisms to detect and correct both underutilization and overutilization of services.
DHS 10.44(4)(d)
(d) Develop and implement a written quality assurance and quality improvement plan designed to ensure and improve outcomes for its target population. The plan shall be approved by the department and shall include at least all of the following components:
DHS 10.44(4)(d)1.
1. Identification of performance goals, specific to the needs of the CMO's enrollees, including any goals specified by the department.
DHS 10.44(4)(d)2.
2. Identification of objective and measurable indicators of whether the identified goals are being achieved, including any indicators specified by the department.
DHS 10.44(4)(d)3.
3. Identification of timelines within which goals for improvement will be achieved.
DHS 10.44(4)(d)4.
4. Description of the process that the CMO will use to gather feedback from enrollees, staff, people who have disenrolled from the CMO and other sources on the quality and effectiveness of the CMO's performance.
DHS 10.44(4)(d)5.
5. A description of the process the CMO will use to monitor and act on the results and feedback received.
DHS 10.44(4)(d)6.
6. A process for regularly updating the plan, including a description of the process the CMO will use for annually assessing the effectiveness of the quality assurance and quality improvement plan and the impact of its implementation on outcomes.
DHS 10.44(4)(e)
(e) Conduct, as specified in its contract with the department, at least one performance improvement project annually that examines aspects of care and services related to improving CMO quality and enrollee outcomes. Each project shall include all of the following:
DHS 10.44(4)(e)4.
4. Planning for sustained or increased improvement in performance, based on the findings of the evaluation.
DHS 10.44(4)(f)
(f) Report all data required by the department related to standardized measures of performance, in the timeframes and format specified by the department.
DHS 10.44(4)(g)
(g) Cooperate with the department in evaluating outcomes and in developing and implementing plans to sustain and improve performance.
DHS 10.44(5)
(5)
External review. A CMO shall comply with all state and federal requirements for external review of quality of care and services furnished to its enrollees. A CMO shall cooperate with any review of CMO activities by the department, another state agency or the federal government.
