Chapter DHS 10

DHS 10.44 History History: 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 10.45 DHS 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) (2) Open enrollment.

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) (4) Reporting and records.

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)(a) (a) A CMO shall provide information as required to comply with s. 16.009 (2) (p) or 49.45 (4), Stats., or as necessary for the department to administer the family care program under ss. 46.2805 to 46.2895, Stats.

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 History History: 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 10.46 DHS 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)(a) (a) Preventable hospitalizations and emergency room visits.

DHS 10.46(3)(b) (b) Voluntary and involuntary disenrollment.

DHS 10.46(3)(c) (c) Pressure sores.

DHS 10.46(3)(d) (d) Movement of members among residential settings.

DHS 10.46(3)(e) (e) Medication management.

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(3)(i) (i) Employment or other activities sought by consumers.

DHS 10.46(3)(j) (j) Influenza vaccinations.

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(4)(a) (a) Fair treatment.

DHS 10.46(4)(b) (b) Privacy.

DHS 10.46(4)(c) (c) Choice of routine.

DHS 10.46(4)(d) (d) Maintenance of family involvement.

DHS 10.46(4)(e) (e) Satisfactory community contact.

DHS 10.46(4)(f) (f) Access to transportation.

DHS 10.46(4)(g) (g) Choice of living arrangement.

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(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).

DHS 10.52(3) (3) Notification of intended adverse benefit determination. Clients shall be given written notice of any intended adverse benefit determination at least 10 days prior to the date of the intended adverse benefit determination in accordance with all of the following:

DHS 10.52(3)(a) (a) Notification shall be provided as follows:

DHS 10.52(3)(a)1. 1. By the county agency in every instance in which a client’s eligibility or entitlement for family care will be discontinued, terminated, suspended or reduced, or in which the client’s maximum cost sharing requirement will be increased.

DHS 10.52(3)(a)2. 2. By the CMO in every instance in which the CMO makes an adverse benefit determination under s. DHS 10.13 (1) (b).

DHS 10.52(3)(b) (b) The notification of intended adverse benefit determination shall include an explanation of all the following, as applicable:

DHS 10.52(3)(b)1. 1. The adverse benefit determination the county agency, resource center or CMO intends to take, including how the adverse benefit determination will affect any services that the applicant or enrollee currently receives.

DHS 10.52(3)(b)1m. 1m. The effective date of the adverse benefit determination.

DHS 10.52(3)(b)2. 2. The reasons for the adverse benefit determination.

DHS 10.52(3)(b)3. 3. Any laws that support the adverse benefit determination.

DHS 10.52(3)(b)4. 4. The applicant’s or enrollee’s right to file an appeal with the CMO or request a fair hearing with the resource center or county agency.

DHS 10.52(3)(b)5. 5. How to file an appeal or a fair hearing and the timelines for doing so.

DHS 10.52(3)(b)5m. 5m. The circumstances under which expedited resolution of an appeal is available and how to request it.

DHS 10.52(3)(b)6. 6. That if the applicant or enrollee files an appeal, he or she has a right to appear in person before the CMO personnel assigned to resolve the appeal.

DHS 10.52(3)(b)7. 7. If the adverse benefit determination will affect any services that the enrollee currently receives through the family care benefit, the circumstances in which the enrollee’s services will be continued under s. DHS 10.56 pending the outcome of an appeal, how the enrollee can request that the services be continued, and the circumstances in which the enrollee may be required to repay the costs of the continued services.