Chapter 648

CHAPTER 648

REGULATION OF CARE MANAGEMENT ORGANIZATIONS

648.01   Definitions.

648.03   Applicability of other laws.

648.05   Permit.

648.10   Powers and duties of the commissioner.

648.15   Reports and replies.

648.20   Examinations.

648.25   Conducting examinations.

648.27   Costs.

648.30   Nondisclosure of information.

648.35   Enforcement procedure.

648.45   Affiliates of permittee.

648.50   Management changes.

648.55   Commissioner’s summary orders.

648.65   Enrollee immunity.

648.75   Insolvency funding.

648.01 648.01 Definitions. In this chapter:

648.01(1) (1) “Care management organization” means an entity described in s. 46.284 (3m).

648.01(2) (2) “Department” means the department of health services.

648.01(3) (3) “Enrollee” has the meaning given in s. 46.2805 (3).

648.01(4) (4) “Permittee” means a care management organization issued a permit under this chapter.

648.01 History History: 2009 a. 28.

648.03 648.03 Applicability of other laws. Notwithstanding s. 600.01 (1) (b) 10. a., ss. 600.01, 600.02, 600.03, and 600.12 apply to this chapter.

648.03 History History: 2009 a. 28.

648.05 648.05 Permit.

648.05(1) (1) Permit required. After December 31, 2009, no care management organization may provide services to its enrollees without a permit under this chapter.

648.05(2) (2) Application. A care management organization applying for a permit shall submit all of the following information in the format required by the commissioner:

648.05(2)(a) (a) The names, addresses and occupations of all controlling persons and directors and principal officers of the care management organization currently and for the preceding 10 years, unless the commissioner waives this requirement.

648.05(2)(b) (b) Business organization documents, including articles and bylaws if applicable.

648.05(2)(c) (c) A business plan approved by the department, including a projection of the anticipated operating results at the end of each of the next 3 years of operation, based on reasonable estimates of income and operating expenses.

648.05(2)(d) (d) Any other relevant documents or information that the commissioner reasonably requires after consulting with the department.

648.05(3) (3) Standards for issuing permit. The commissioner may issue a permit to the care management organization if the commissioner finds, after consulting with the department, all of the following:

648.05(3)(a) (a) All requirements of law have been met.

648.05(3)(b) (b) All the directors and principal officers or any controlling person are trustworthy and competent and collectively have the competence and experience to engage in the proposed services and are not excluded from participation under 42 USC 1320a-7 or 42 USC 1320a-7a.

648.05(3)(c) (c) The business plan is consistent with the interests of the care management organization’s enrollees and the public.

648.05(4) (4) Suspension or revocation. The commissioner may suspend or revoke a permit issued under this chapter if the commissioner finds, after consulting with the department, any of the following:

648.05(4)(a) (a) The permittee violated a law or rule, including a rule establishing standards for the financial condition of care management organizations.

648.05(4)(b) (b) The permittee is in a financially hazardous condition.

648.05(4)(c) (c) The permittee is controlled or managed by persons who are incompetent or untrustworthy.

648.05(4)(d) (d) The permittee conceals records from the commissioner.

648.05(4)(e) (e) The permittee’s business plan is not in the public interest or is not prudent.

648.05(4)(f) (f) The permittee ceases to be certified by or maintain a contract with the department.

648.05 History History: 2009 a. 28.

648.10 648.10 Powers and duties of the commissioner. The commissioner may do any of the following:

648.10(1) (1) Promulgate rules that are necessary to carry out the intent of this chapter, including, after consulting with the department, standards for the financial condition of care management organizations.

648.10(2) (2) Use the authority granted under ss. 601.41, 601.42, 601.43, 601.44, 601.61, 601.62, 601.63, and 601.64, including the authority to issue orders, to enforce this chapter and to ensure that a care management organization has sufficient financial resources.

648.10 History History: 2009 a. 28.

648.10 Cross-reference Cross-reference: See also ch. Ins 57, Wis. adm. code.

648.15 648.15 Reports and replies.

648.15(1) (1) Reports. The commissioner may require from any care management organization any of the following:

648.15(1)(a) (a) Statements, reports, answers to questionnaires, and other information in whatever reasonable form the commissioner designates and at such reasonable intervals as the commissioner chooses, or from time to time.

648.15(1)(b) (b) Full explanation of the programming of any data storage or communication system in use.

648.15(1)(c) (c) Information from any books, records, electronic data processing systems, computers, or any other information storage system at any reasonable time in any reasonable manner.

648.15(1)(d) (d) Statements, reports, audits, or certification from a certified public accountant or an actuary approved by the commissioner.

648.15(2) (2) Forms. The commissioner, after consulting with the department, may prescribe forms for the reports under sub. (1) and specify who shall execute or certify such reports.

648.15(3) (3) Accounting methods. The commissioner, after consulting with the department, may prescribe reasonable minimum standards and techniques of accounting and data handling to ensure that timely and reliable information will exist and will be available to the commissioner.

648.15(4) (4) Replies. Any officer or manager of a care management organization, any person controlling or having a contract under which the person has a right to control a care management organization, whether exclusively or otherwise, or any person with executive authority over or in charge of any segment of such a care management organization’s affairs, shall reply promptly in writing or in another designated form, to any written inquiry from the commissioner requesting a reply.

648.15(5) (5) Verification. The commissioner may require that any communication made to the commissioner under this section be verified.

648.15(6) (6) Immunity. In the absence of actual malice, no person shall be subject to damages in an action for defamation based on a communication to the commissioner required by law under this chapter or by the commissioner under this chapter.

648.15(7) (7) Experts. The commissioner may employ experts to assist the commissioner in an examination or in the review of any transaction subject to approval under this chapter. The care management organization that is the subject of the examination, or that is a party to a transaction under review, including the person acquiring, controlling, or attempting to acquire the care management organization, shall pay the reasonable costs incurred by the commissioner for the expert and related expenses.

648.15 History History: 2009 a. 28.

648.20 648.20 Examinations.

648.20(1) (1) Power to examine.

648.20(1)(a) (a) To inform himself or herself about a matter related to the enforcement of this chapter, the commissioner may examine the affairs and condition of any permittee.

648.20(1)(b) (b) So far as reasonably necessary for an examination under par. (a), the commissioner may examine the accounts, records, or documents so far as they relate to the permittee, of any of the following:

648.20(1)(b)1. 1. An officer, manager, employee, or person who has executive authority over or is in charge of any segment of the permittee’s affairs.

648.20(1)(b)2. 2. A person controlling or having a contract under which the person has the right to control the permittee whether exclusively or with others.

648.20(1)(b)3. 3. A person who is under the control of the permittee, or a person who is under the control of a person who controls or has a right to control the permittee whether exclusively or with others.

648.20(1)(c) (c) On demand, every permittee shall make available to the commissioner for examination any of its own accounts, records, documents, or evidences of transactions.

648.20(1)(d) (d) On order of the commissioner any examinee under this chapter shall bring to the office for examination such records as the order reasonably requires.

648.20(2) (2) Audits or actuarial or other evaluations. In lieu of all or part of an examination under sub. (1), or in addition to it, the commissioner may order an independent audit by certified public accountants or an actuarial or other evaluation by actuaries or other experts approved by the commissioner of any permittee. Any accountant, actuary, or other expert selected is subject to rules respecting conflicts of interest promulgated by the commissioner. Any audit or evaluation under this section is subject to s. 648.25, so far as applicable.

648.20(3) (3) Alternatives to examination. In lieu of all or part of an examination under this section, the commissioner may accept the report of an audit already made by certified public accountants or of an actuarial or other evaluation already made by actuaries or other experts approved by the commissioner, or the report of an examination made by another government agency in this state, the federal government, or another state.

648.20(4) (4) Purpose and scope of examination. An examination may but need not cover comprehensively all aspects of the permittee’s affairs and condition. The commissioner shall determine the exact nature and scope of each examination, and in doing so shall take into account all relevant factors, including the length of time the permittee has been doing business, the length of time the permittee has been certified by the department, the nature of the business being examined, the nature of the accounting records available, and the nature of examinations performed elsewhere.

648.20 History History: 2009 a. 28.

648.25 648.25 Conducting examinations.

648.25(1) (1) Order of examination. For each examination under s. 648.20, the commissioner shall issue an order stating the scope of the examination and designating the examiner in charge. Upon demand, a copy of the order shall be provided to the examinee.

648.25(2) (2) Access to examinee. Any examiner authorized by the commissioner shall, for the purposes of the examination, have access at all reasonable hours to the premises and to any property of the examinee.