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)2. 2. Continuity and coordination of care.

DHS 10.44(4)(c)3. 3. Coverage and authorization of services.

DHS 10.44(4)(c)4. 4. Provision of information to enrollees.

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)1. 1. Measuring performance.

DHS 10.44(4)(e)2. 2. Implementing system interventions.

DHS 10.44(4)(e)3. 3. Evaluating the effectiveness of the interventions.

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.

DHS 10.44 Note Note: All enrollees in Family Care are encouraged to participate in the direction of their own care and supports as much as they are willing and able. The full range of self-determination is to be encouraged and supported for all enrollees, including identification and setting priorities among long-term care outcomes, and direction of all long-term care services and health care, including end-of-life issues. As provided under s. DHS 10.44 (2) (e) and (f), all enrollees are to be full partners in the assessment of needs and strengths and in the development of care plans. Provisions at s. DHS 10.44 (2) (h) and (3) (d) require that each enrollee is to be offered the opportunity to take as much responsibility as he or she is willing and able in the selection, arrangement and monitoring of services.

DHS 10.44 Note Note: The option provided in the following sub. (6) is one in which the enrollee takes full responsibility for managing the funding for all or part of his or her services, with some oversight from the CMO. Primary differences from the usual Family Care model are: (1) the ability to purchase services from outside the CMO network of providers; (2) the ability to receive assistance in planning, arranging and monitoring services from a broker or case manager outside the CMO; and (3) within the individual’s established budget, having a greater degree of control over payment, including adjustments to payment rates, for services received.