Wisconsin Legislature: DHS 105.52(1)(d)

Alert! This chapter may be affected by an emergency rule:

EmR2421

(2) Employed personnel.

(a) To provide case assessment or case planning services reimbursable under MA, persons employed by or under contract to the case management agency under sub. (1) shall:

1. Possess a degree in a human services-related field, possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed, and have acquired at least one year of supervised experience with the type of recipients with whom he or she will work; or

2. Possess 2 years of supervised experience or an equivalent combination of training and experience.

Note: The knowledge required in subd. 1. is typically gained through supervised experience working with persons in the target population.

(b) To provide ongoing monitoring and service coordination reimbursable under MA, personnel employed by a case management agency under sub. (1) shall possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed.

(3) Sufficiency of agency certification for employed personnel. Individuals employed by or under contract to an agency certified to provide case management services under this section may provide case management services upon the department’s issuance of certification to the agency. The agency shall maintain a list of the names of individuals employed by or under contract to the agency who are performing case management services for which reimbursement may be claimed under MA. This list shall certify the credentials possessed by the named individuals which qualify them under the standards specified in sub. (2). Upon request, an agency shall promptly advise the department in writing of the employment of persons who will be providing case management services under MA and the termination of employees who have been providing case management services under MA.

(4) Contracted personnel. Persons under contract with a certified case management agency to provide assessments or case plans shall meet the requirements of sub. (2) (a), and to provide ongoing monitoring and service coordination, shall meet the requirements of sub. (2) (b).

(5) Recordkeeping. The case manager under s. DHS 107.32 (1) (d) shall maintain a file for each recipient receiving case management services which includes the following:

(a) The assessment document;

(b) The case plan;

(d) Financial forms;

(e) Release of information forms;

(f) Case reviews;

(g) A written record of all monitoring and quality assurance activities; and

(h) All pertinent correspondence relating to the recipient’s case management.

(6) Reimbursement.

(a) Case management services shall be reimbursed when the services are provided by certified providers or their subcontractors to recipients eligible for case management.

(b) Payment shall be made to certified providers of case management services according to terms of reimbursement established by the department.

(7) County election to participate.

(a) The department may not certify a case management agency for a target population unless the county board or tribal government of the area in which the agency will operate has elected to participate in providing benefits under s. DHS 107.32 through providers operating in the county or tribal area. The county board or tribal government may terminate or modify its participation by giving a 30 day written notice to the department. This election is binding on any case management agencies providing services within the affected county or tribal area.

(b) Any case management agency provider requesting certification under this section shall provide written proof of the election of the county or tribal government to participate under this subsection.

History: Cr. Register, February, 1988, No. 386, eff. 3-1-88; corrections in (1) (a), (5) (intro.) and (7) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.52 Prenatal care coordination providers.

(1) Agency. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be:

(a) A community-based health organization;

(b) A community-based social services agency or organization;

(d) A county department of human services under s. 46.23, Stats., or social services under s. 46.215 or 46.22, Stats.;

(e) A family planning agency certified under s. DHS 105.36;

(f) A federally qualified health center (FQHC) as defined in 42 CFR 405.2401 (b);

(g) A health maintenance organization (HMO);

(h) An independent physician association (IPA);

(i) A hospital;

(j) A physician’s office or clinic;

(k) A private case management agency;

(L) A registered nurse or nurse practitioner;

(m) A rural health clinic certified under s. DHS 105.35;

(n) A tribal agency health center; or

(o) A women, infants, and children (WIC) program under 42 USC 1786.

(2) Qualified professionals.

(a) Definition. In this subsection, “qualified professional” means any of the following:

1. A nurse practitioner licensed as a registered nurse pursuant to s. 441.06, Stats., and currently certified by the American nurses’ association, the national board of pediatric nurse practitioners and associates or the nurses’ association of the American college of obstetricians and gynecologists’ certification corporation;

2. A nurse midwife certified under s. DHS 105.201;

3. A public health nurse meeting the qualifications of s. DHS 139.08;

4. A physician licensed under ch. 448, Stats., to practice medicine or osteopathy;

5. A physician assistant certified under ch. 448, Stats.;

6. A dietitian certified or eligible for registration by the commission on dietetic registration of the American dietetic association with at least 2 years of community health experience;

7. A registered nurse with at least 2 years of experience in maternity nursing or community health services or a combination of maternity nursing and community health services;

8. An employee with at least a bachelor’s degree and 2 years of experience in a health care or family services program; or

9. A health educator with a master’s degree in health education and at least 2 years of experience in community health services.

(b) Required qualified professionals. To be certified to provide prenatal care coordination services that are reimbursable under MA, the prenatal care coordination agency under sub. (1) shall:

1. Employ at least one qualified professional with at least 2 years of experience in coordinating services for at-risk or low income women;

2. Have on staff, under contract or available in a volunteer capacity a qualified professional to supervise risk assessment and ongoing care coordination and monitoring; and

3. Have on staff, under contract or available in a volunteer capacity one or more qualified professionals with the necessary expertise, based on education or at least one year of work experience, to provide health education and nutrition counseling.

(3) Sufficiency of agency certification. Individuals employed by or under contract with an agency that is certified to provide prenatal care coordination services under this section may provide prenatal care coordination services upon the department’s issuance of certification to the agency. The agency shall maintain a list of all persons who provide or supervise the provision of prenatal care coordination services. The list shall include the credentials of each named individual who is qualified to supervise risk assessment and ongoing care coordination under sub. (2) (b) 2. and to provide health education or nutrition counseling under sub. (2) (b) 3. Upon the department’s request, an agency shall promptly report to the department in writing the names of persons hired to provide prenatal care coordination services under MA and the termination of employees who have been providing prenatal care coordination services under MA.

(4) Administrative records and required documentation. To be certified to provide prenatal care coordination services reimbursable under MA, the prenatal care coordination agency under sub. (1) shall comply with s. DHS 106.02 (9) and shall submit a plan to the department documenting:

(a) That the agency is located in the area it will serve;

(b) That the agency has a variety of techniques to identify low-income pregnant women;

(c) That, at a minimum, the agency has the name, location and telephone number of the following resources in the area to be served:

1. Women, infants, and children (WIC) programs;

2. Maternal and child health services;

3. The county, city, or combined city and county public health agency;

4. Child day care services;

5. Mental health and alcohol or other drug abuse prevention and treatment agencies;

6. The county protective service agency;

7. Domestic abuse agencies;

8. Translator and interpreter services including services for the hearing-impaired;

9. Family support services;

10. Transportation services; and

11. MA-certified primary care and obstetric providers, including health maintenance organizations participating in the medical assistance program’s HMO program.

(d) That the agency, if located in a county with health maintenance organizations (HMO) participating in the medical assistance HMO program, has on file a signed copy of a memorandum of understanding with each HMO participating in the medical assistance HMO program in the county;

(e) That the agency has contacted in writing MA-certified primary and obstetric care providers in its area and has identified the types of services the prenatal care coordination agency provides. These contacts and this information shall be documented and the documentation retained in the agency’s administrative records;

(f) That the agency has the ability and willingness to deliver services in a manner that is sensitive to the particular characteristics of the racial or ethnic group or groups with which it intends to work. Documentation of that ability shall be maintained and kept up-to-date. Documentation shall consist of one or more of the following at all times:

1. Records showing the racial and ethnic composition of the population served in the past;

2. Records showing that the agency has developed, implemented and evaluated programs specifically targeted toward the racial or ethnic group or groups;

3. Records showing that the agency has provided health care services in a geographic area where a significant percentage of the population was the same as the agency’s targeted racial or ethnic group or groups;

4. Evidence that the agency’s board or administration has a significant amount of representation from the targeted group or groups;

5. Letters of support from minority health service organizations which represent the targeted group or groups; or

6. Evidence of the agency’s ability to address pertinent cultural issues such as cultural norms and beliefs, language, outreach networking and extended family relationships;

(g) That the agency has the ability to arrange for supportive services provided by other funding sources such as county transportation, county protective services, interpreter services, child care services and housing. This description shall include the methods, techniques and contacts which will be used to offer and provide assistance in accessing those services;

(h) That the agency has the capability to provide ongoing prenatal care coordination monitoring of high-risk pregnant women and to ensure that all necessary services are obtained; and

(i) That the agency has on staff, under contract or available in a volunteer capacity, individuals who are qualified professionals under sub. (2) (a) with the expertise required under sub. (2) (b).

(5) Recipient record. The prenatal care coordination agency shall maintain a confidential prenatal care coordination file for each recipient receiving prenatal care coordination services, which includes the following items required or produced in connection with provision of covered services under s. DHS 107.34 (1):

(a) Verification of the pregnancy;

(b) Completed risk assessment document;

(d) Completed consent documents for release of information;