DHS 10.44(6)(c)8.8. The individual service plan for each enrollee participating in the self-managed service funding mechanism and the plan under subd. 6. includes a plan for how the CMO will monitor all of the following: DHS 10.44(6)(c)8.a.a. The health and safety of the enrollee and other people are not significantly threatened. DHS 10.44(6)(c)8.b.b. The enrollee’s expenditures are consistent with the budget established under subd. 5. and the plan established under subd. 6. DHS 10.44(6)(c)8.c.c. Safeguards are in place to ensure that the conflicting interests of other people are not taking precedence over the desires and interests of the enrollee. DHS 10.44(6)(c)9.9. If the self-managed expenditures of CMO enrollees are less than the amounts budgeted under subd. 5., the savings are used only for services and supports consistent with the long-term care outcomes of enrollees, as identified under sub. (2) (e) 2. Savings shall not be used for administrative costs of a CMO. DHS 10.44(6)(c)10.10. The self-managed supports budget for an enrollee is not reduced in a subsequent year solely because the enrollee did not expend the full amount budgeted in a given year. Each year’s budget is based on a re-assessment of needs and identified long-term care outcomes under subd. 5. DHS 10.44(6)(c)11.11. The CMO has in place policies and procedures under which the enrollee can make or authorize payments to providers and receive timely information on expenditures made and budget status. DHS 10.44(6)(c)12.12. The policies and procedures under subd. 11. include mechanisms for assuring compliance with requirements for the deduction and payment of payroll taxes and for providing legally mandated fringe benefits for individuals employed by the enrollee and makes assistance available to the enrollee for all of the following employment-related tasks: DHS 10.44(6)(c)12.h.h. Setting the level of benefits, if any, to be provided in addition to requisite state and federal payroll benefits, such as vacation, sick leave or health insurance. DHS 10.44(6)(c)13.13. The CMO has policies and procedures under which the CMO may restrict the level of self-management of service funding exercised by an enrollee or for increasing the level of involvement of the case management team where the team finds any of the following: DHS 10.44(6)(c)13.b.b. The enrollee’s expenditures are inconsistent with the budget established under subd. 5. and the plan established under subd. 6. DHS 10.44(6)(c)13.c.c. The conflicting interests of another person are taking precedence over the desires and interests of the enrollee. DHS 10.44(6)(c)13.e.e. Negative consequences have occurred under other policies approved by the department. DHS 10.44(6)(c)14.14. The CMO informs each enrollee whose level of self-management of service funding is restricted under subd. 13. about what actions by the enrollee will result in removal of the restrictions. DHS 10.44(6)(c)15.15. The CMO informs the enrollee whose level of self-management of service funding is restricted under subd. 13. about his or her right 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 if he or she disagrees with any limit on the level of self-management. DHS 10.44(6)(c)16.16. The CMO has policies and procedures in place related to self-management of service funding of an enrollee under guardianship that include all of the following: DHS 10.44(6)(c)16.a.a. Training for guardians to assist them in learning and respecting enrollees’ preferences and goals. DHS 10.44(6)(c)16.b.b. Assistance to enrollees and their guardians in building the enrollees’ skills in the area of self-determination. DHS 10.44(6)(c)16.c.c. Periodic re-assessment of enrollees’ competency to exercise rights directly and assistance to enrollees in attaining or regaining rights the CMO believes they are competent to exercise. DHS 10.44 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (4) (c) 5. Register November 2004 No. 587, eff. 12-1-04; EmR2121: am. (2) (e), eff. 8-5-21; CR 21-081: am. (2) (e) (intro.) Register May 2022 No. 797, eff. 6-1-22, am. (2) (e) (intro.) eff. upon the termination of the Appendix K: Emergency Preparedness and Response and COVID-19 Addendum to the 1915 (c) Family Care program waiver. DHS 10.45DHS 10.45 Operational requirements for CMOs. DHS 10.45(1)(1) Governing board. A care management organization shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the CMO. At least one-fourth of the members of the governing board shall be older persons or persons with physical or developmental disabilities or their family members, guardians or other advocates who are representative of the CMO’s enrollees. DHS 10.45(2)(a)(a) Except as provided in s. DHS 10.36 (2), a CMO shall conduct a continuous open enrollment period, accepting enrollment of any member of its target population who is enrolled by an aging and disability resource center serving the area of the CMO, without regard to life situation, health or disability status or cost sharing requirements. DHS 10.45(2)(b)(b) A CMO may not disenroll any enrollee except under circumstances specified in its contract with the department and the express approval of the department, unless the enrollee has requested to be disenrolled. When a CMO requests department approval to disenroll an enrollee, the CMO shall refer the enrollee to the resource center for counseling under s. DHS 10.23 (2) (j). A CMO may not encourage any enrollee to disenroll. DHS 10.45(3)(3) Service to private pay individuals. The CMO shall provide, on a fee-for-service basis, case management and other services to private pay individuals as necessary to meet the requirements specified in s. DHS 10.37. DHS 10.45(4)(a)(a) The department shall require each CMO to report information as the department determines necessary, including information needed for all of the following: DHS 10.45(4)(a)1.1. Determination of whether the CMO is meeting minimum quality standards, including adequate long-term care outcomes for its enrollees. DHS 10.45(4)(a)2.2. Determination of the extent to which the CMO is improving its performance on measurable indicators identified by the CMO in its current quality improvement plan. DHS 10.45(4)(a)3.3. Determination of whether the CMO is meeting the requirements of its contract with the department. DHS 10.45(4)(a)4.4. Determination of the adequacy of the CMO’s fiscal management and financial solvency. DHS 10.45(4)(a)5.5. Evaluation of the effects for enrollees and cost-effectiveness of providing the family care benefit. DHS 10.45(4)(b)(b) A CMO shall submit to the department all reports and data required or requested by the department, in the format and timeframe specified by the department. DHS 10.45(5)(5) Confidentiality and exchange of information. No record, as defined in s. 19.32 (2), Stats., of a CMO that contains personally identifiable information, as defined in s. 19.62 (5), Stats., concerning a current or former enrollee may be disclosed by the CMO without the individual’s informed consent, except as follows: DHS 10.45(5)(b)(b) Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.22, 146.82, 252.11 (7), 253.07 (3) (c) and 938.78 (2) (a), Stats., a CMO may exchange confidential information about a client without the informed consent of the client, in the county of the CMO, if necessary to enable the CMO to perform its duties or to coordinate the delivery of services to the client, as authorized under s. 46.21 (2m) (c), 46.215 (1m), 46.22 (1) (dm), 46.23 (3) (e), 46.283 (7), 46.2895 (10), 51.42 (3) (e) or 51.437 (4r) (b), Stats. DHS 10.45 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction in (5) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; EmR2121: r. (2) (b), eff. 8-5-21; CR 21-081: am. (2) (e) Register May 2022 No. 797, eff. 6-1-22, am. (2) (b) eff. the first day of the month after the emergency period, as defined in section 1135 (g) (1) (b) of the Social Security Act, 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (2) (b) made under s. 35.17, Stats., Register May 2022 No. 797. DHS 10.46DHS 10.46 Department responsibilities for monitoring CMO quality and operations. DHS 10.46(1)(1) Monitoring. The department shall monitor CMO operations to assure quality of services and delivery, including consumer satisfaction. The department shall develop indicators to measure and assess quality in all of the following areas: DHS 10.46(1)(a)(a) Family care benefit effectiveness in increasing consumer long-term care choices, including choice of services, service providers, living arrangement and daily routine. DHS 10.46(1)(b)(b) Family care benefit effectiveness in improving access to long-term care services to support member care and choice of living arrangement. DHS 10.46(1)(c)(c) Family care benefit effectiveness at meeting the expectations of members in care and services received, reliability of the long-term care system and providers, fair and respectful treatment and privacy. DHS 10.46(1)(d)(d) Family care benefit effectiveness in assuring member health and safety, including being free from abuse and neglect, being protected against misappropriation of funds, being safe in chosen living arrangement, and receiving needed health services, consistent with member choices and preferences. DHS 10.46(2)(2) Indicators. The department shall measure and assess CMOs’ quality based on the areas in sub. (1) by establishing indicators. The department shall use indicators to compare performance within and across CMOs and against other programs to help improve CMO performance and ensure quality. Where possible, the department shall measure indicators against available or created benchmarks and evaluate CMOs’ performance. The department shall assess the CMO’s performance for the non-quantifiable indicators by using an assessment mechanism based on outcome measurement. DHS 10.46(3)(3) Measurement indicators. The department shall measure at least the following indicators: DHS 10.46(3)(f)(f) Grievances, appeals and fair hearings and their disposition. DHS 10.46(3)(g)(g) Providers with consumers on governance boards and committees. DHS 10.46(3)(h)(h) Change in ability to carry out activities of daily living. DHS 10.46(4)(4) Assessment indicators. The department shall assess CMOs in meeting member needs through qualitative indicators in at least the following areas: DHS 10.46(5)(5) Cost- effectiveness. The department shall measure: DHS 10.46(5)(a)(a) CMO cost-effectiveness in meeting member needs within available resources. 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 HistoryHistory: 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. DHS 10.51DHS 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)(c)(c) Prompt eligibility, entitlement and cost-sharing decisions and assistance.
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Department of Health Services (DHS)
Chs. DHS 1-19; Management and Technology and Strategic Finance
administrativecode/DHS 10.44(6)(c)16.
administrativecode/DHS 10.44(6)(c)16.
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