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)(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(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 NoteNote: 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 NoteNote: 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.

DHS 10.44(6)(a)(a) The CMO shall provide enrollees with an opportunity to manage funding for services and supports, including an opportunity for an enrollee who chooses to participate to plan, arrange for, manage and monitor services under his or her family care benefit directly or with the assistance of another person chosen by the enrollee. The department may, through its contract with the CMO, limit the self-management of services not covered by federal home and community based waivers under 42 USC 1396n (c). The CMO shall provide the opportunity to self-manage service funding under a plan approved by the department under par. (b) or (c).

DHS 10.44(6)(b)1.1. The CMO offers the opportunity to participate in self-managing all or some of the funding for his or her services under par. (a), with the assistance and support described in this paragraph, to a significant number of enrollees, and has a phase-in plan under which the opportunity to self-manage service funding is offered to an increasing number of enrollees in each year.

DHS 10.44(6)(b)2.2. For individuals participating in a self-management option, the plan complies with the provisions of par. (c) or, for any provision with which the plan does not comply, provides interim procedures and a plan and time-frame for achieving compliance.

DHS 10.44(6)(c)(c) On or after January 1, 2003, the department may approve the CMO plan for self-managed service funding only if the plan provides all of the following:

DHS 10.44(6)(c)1.1. The CMO offers each enrollee the opportunity to self-manage some or all of the funding for his or her services under par. (a), with the assistance and support described in this paragraph.

DHS 10.44(6)(c)2.2. The CMO, as part of the comprehensive assessment under sub. (2) (e), identifies whether the enrollee needs support to effectively self-manage funding for his or her services, whether needed support is available to the person from one or more other persons, and whether the enrollee will accept the needed help. If the CMO determines that an enrollee who wants to self-manage his or her service funding is not able to do so independently and that the support available and acceptable to an enrollee is insufficient to support the person to effectively plan and manage funding for services and supports, the CMO, through the case management team, shall do all of the following:

DHS 10.44(6)(c)2.a.a. Work with the enrollee and available supports to develop a case plan that specifies any limits on the level of control exercised by the enrollee that the CMO finds necessary under subd. 13.

DHS 10.44(6)(c)2.d.d. Inform the enrollee of his or her right to file a grievance under s. DHS 10.53, request department review under s. DHS 10.54, or request a fair hearing under s. DHS 10.55 if he or she disagrees with the determination of need for support or the level of self-management provided by the plan.

DHS 10.44(6)(c)3.3. The CMO offers training in the effective planning and management of service funding and supports to enrollees using the self-managed service funding mechanism and to individuals assisting these enrollees to manage funding for their services.

DHS 10.44(6)(c)4.4. Subject to any limitations under subd. 2., the enrollee may choose the long-term care outcomes for which he or she wishes to manage funding for services or supports directly and the degree to which he or she wishes the CMO to assist in the management of funding for those services or supports beyond the minimum described in sub. (2) (d).

DHS 10.44(6)(c)5.5. The CMO has a system in place for establishing and modifying an individualized budget amount or range available to the enrollee to pay for the services and supports to be self-managed. The individualized budget amount or range is based on the comprehensive assessment and on a methodology approved by the department for estimating the cost of services the CMO would have provided if the funding for the services and supports were not self-managed.

DHS 10.44(6)(c)6.6. The enrollee submits a plan for managing funding for those supports or services the member has chosen to manage directly. The CMO reviews the plan to ensure that the plan does not jeopardize the enrollee’s health and safety and that expenditures are within the budget agreed to by the CMO and meets any other condition approved by the department.

DHS 10.44(6)(c)7.7. Within the budget established under subd. 5. and the plan established under subd. 6., the enrollee may purchase any service or support consistent with the long-term care outcomes identified under sub. (2) (e) 2., including assistance with planning and coordinating services to the extent that this assistance is not provided by the CMO.

DHS 10.44(6)(c)8.8. The individual service plan for each enrollee participating in the self-managed service funding mechanism and the plan under subd. 6. includes a plan for how the CMO will monitor all of the following: