DHS 107.28(1)(a)1.1. Except as provided in subd. 2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covered services at the time the medicaid HMO contract becomes effective with the exception of the following:

DHS 107.28(1)(a)2.2. The department may permit an HMO to provide less than comprehensive coverage, but only if there is adequate justification and only if commitment is expressed by the HMO to progress to comprehensive coverage.

DHS 107.28(1)(b)(b) Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.

DHS 107.28(1)(c)(c) Family care benefit. A care management organization under contract with the department to provide the family care benefit under s. DHS 10.41 shall provide those MA services specified in its contract with the department and shall meet all applicable requirements under ch. DHS 10.

DHS 107.28(2)(2) Contracts. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall:

DHS 107.28(2)(d)(d) Specify any procedures for enrollment or reenrollment of the recipients;

DHS 107.28(2)(e)(e) Specify the amount, duration and scope of medical services to be covered;

DHS 107.28(2)(f)(f) Provide that the department may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed under the contract;

DHS 107.28(2)(g)(g) Provide that the department may audit and inspect any of the contractor’s records that pertain to services performed and the determination of amounts payable under the contract and stipulate the required record retention procedures;

DHS 107.28(2)(i)(i) Specify activities to be performed by the contractor that are related to third-party liability requirements; and

DHS 107.28(2)(j)(j) Specify which functions or services may be subcontracted and the requirements for subcontracts.

DHS 107.28(3)(a)(a) Allow each enrolled recipient to choose a health professional in the organization to the extent possible and appropriate;

DHS 107.28(3)(b)1.1. Provide that all medical services that are covered under the contract and that are required on an emergency basis are available on a 24-hour basis, 7 days a week, either in the contractor’s own facilities or through arrangements, approved by the department, with another provider; and

DHS 107.28(3)(b)2.2. Provide for prompt payment by the contractor, at levels approved by the department, for all services that are required by the contract, furnished by providers who do not have arrangements with the contractor to provide the services, and are medically necessary to avoid endangering the recipient’s health or causing severe pain and discomfort that would occur if the recipient had to use the contractor’s facilities;

DHS 107.28(3)(c)1.1. Is approved in writing by the department;

DHS 107.28(3)(c)2.2. Provides for prompt resolution of the grievance; and

DHS 107.28(3)(c)3.3. Assures the participation of individuals with authority to require corrective action;