Section 10.44. Standards for performance by CMOs.

 

(1)   Compliance. A care management organization shall comply with all applicable statutes, all of the standards in this subchapter and all requirements of its contract with the department.

(2)   Case management standards. The CMO shall provide case management services that meet all of the following standards:

(a) The CMO's case management personnel shall meet staff qualification standards contained in its contract with the department.

(b) The CMO shall designate for each enrollee a case management team that includes at least a social service coordinator and a registered nurse. The CMO shall designate additional members of the team as necessary to ensure that expertise needed to assess and plan for meeting each member's needs is available.

(c) The CMO shall employ or contract with a sufficient number of case management personnel to ensure that enrollees' services continue to meet their needs.

(d) The CMO shall provide the opportunity for enrollees to manage service and support funds, as provided under sub. (6) . For enrollees managing service funding under sub. (6) , the role of the case management team in providing assistance in planning, arranging, managing and monitoring the enrollee's budget and services shall be negotiated between the enrollee and the case management team and at a level tailored to the enrollee's need and desire for assistance. At a minimum, the case management team's role shall include:

1. An initial assessment sufficient to provide information necessary to establish an individual budget amount and to identify health and safety issues.

2. Monitoring the enrollee's use of the individual budget amount for purchase of services or support items.

3. Monitoring the health and safety of the enrollee.

4. Monitoring to ensure the enrollee reports service utilization adequately to allow the CMO to meet federal and state reporting requirements.

(e) The CMO shall use assessment protocols that include a face-to-face interview with the enrollee and that comprehensively assess and identify all of the following:

1. The needs and strengths of each enrollee in at least the following areas:

a. Activities of daily living and instrumental activities of daily living.

b. Physical health and medical needs.

c. Nutrition.

d. Autonomy and self-determination.

e. Communication.

f. Mental health and cognition.

g. Presence of, and opportunities for enhancing, informal supports.

h. Understanding and exercising rights and responsibilities.

i. Community integration.

j. Safety.

k. Personal values.

L. Education and vocational activities, including any needs for job development, job modifications, and ongoing support on the job.

m. Economic resources.

n. Religious affiliations, if any.

2. Long-term care outcomes that are consistent with the values and preferences of the enrollee in at least the following areas:

a. Safety.

b. Best possible health.

c. Self-determination of daily routine, services, activities and living situation.

d. Privacy.

e. Respect.

f. Independence.

g. Social roles and ties to family, friends and community.

h. Educational and vocational activities.

i. Desired level and type of participation in community life.

j. Spiritual needs and desired participation in religious activities.

(f) The CMO, in partnership with the enrollee, shall develop an individual service plan for each enrollee, with the full participation of the enrollee and any family members or other representatives that the enrollee wishes to participate. The CMO shall provide support, as needed, to enable the enrollee, family members or other representatives to make informed service plan decisions, and for the enrollee to participate as a full partner in the entire assessment and individual service plan development process. The service plan shall meet all of the following conditions:

1. Reasonably and effectively addresses all of the long-term care needs and utilizes all enrollee strengths and informal supports identified in the comprehensive assessment under par. (e) 1.

2. Reasonably and effectively addresses all of the enrollee's long-term care outcomes identified in the comprehensive assessment under par. (e) 2. and assists the enrollee to be as self-reliant and autonomous as possible and desired by the enrollee.

3. Is cost-effective compared to alternative services or supports that could meet the same needs and achieve similar outcomes.

4. Is agreed to by the enrollee, except as provided in subd. 5.

5. If the enrollee and the CMO do not agree on a service plan, provide a method for the enrollee 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 . Pending the outcome of the grievance, review or fair hearing, the CMO shall offer its service plan for the enrollee, continue negotiating with the enrollee and document that the service plan meets all of the following conditions:

a. Meets the conditions specified under subds. 1. to 3.

b. Would not have a significant, long-term negative impact on the enrollee's long-term care outcomes identified under par. (e) 2.

c. Balances the needs and outcomes identified by the comprehensive assessment with reasonable cost, immediate availability of services and ability of the CMO to develop alternative services and living arrangements.

d. Was developed after active negotiation between the CMO and the enrollee, during which the CMO offered to find or develop alternatives that would be more acceptable to both parties.

(g) The CMO shall reassess each enrollee's needs and strengths as specified under par. (e) 1. and long-term care outcomes as specified under par. (e) 2. and adjust the individual service plan based on the findings of the re-assessment, as specified in par. (j) 5.

(h) The CMO shall provide, arrange, coordinate and monitor services as required by its contract with the department and as specified in the enrollee's individual service plan. The CMO shall provide opportunity for each enrollee to be involved, to the extent that he or she is able and willing, in all of the following:

1. The selection of service providers from within the CMO's network of providers.

2. The recruiting, interviewing, hiring, training and supervision of individuals providing personal care and household assistance in the enrollee's home.

(i) The CMO shall provide assistance to enrollees in arranging for and coordinating services that are outside the direct responsibility of the CMO.

(j) The CMO shall meet timeliness standards as specified in its contract with the department, that shall include all of the following:

1. Immediately upon enrollment, the CMO shall provide services to preserve the health and safety of the enrollee. Within 5 days of enrollment, the CMO shall develop and implement an initial service plan based on information received from the resource center and the CMO's initial assessment of the enrollee's needs.

2. The CMO shall complete a comprehensive assessment, as specified under par. (e) not later than 30 days after enrollment.

3. Within 60 days of enrollment, the CMO shall, jointly with the enrollee and any other individual identified by the enrollee, develop an individualized service plan as specified under par. (f) .

4. The CMO shall provide services and support items in accordance with the time frames specified in each enrollee's individualized service plan.

5. The CMO shall review each enrollee's service plan and adjust services if indicated by the review, as follows:

a. Whenever a significant change occurs in the enrollee's health, functional capacity or other circumstances.

b. When requested by the enrollee, the enrollee's representative, the enrollee's primary medical provider, or an agency providing services to the enrollee.

c. As often as necessary in relation to the stability of the enrollee's health and circumstances, but not less than every 180 days.

6. The CMO shall provide required reports in a timely manner as specified in its contract with the department.

(3)   Service monitoring. A CMO shall do all the following:

(a) Develop and implement standards for CMO service provider qualifications and written procedures and protocols for assessing whether providers meet the standards. Provider qualification standards established by a CMO shall meet or exceed standards that are specified in its contract with the department.

(b) Develop and implement written procedures and protocols that assure that services furnished are consistent with the needs and strengths identified under sub. (2) (e) 1. , the long-term care outcomes identified under sub. (2) (e) 2. and the individual service plan under sub. (2) (f) for each enrollee.

(c) Develop and implement written procedures and protocols that assure that enrollee problems related to services are detected and promptly addressed.

(d) Maintain a process to consider an enrollee's request to receive services from a provider who does not have an agreement with the CMO for providing services to the CMO's enrollees. The CMO shall arrange for services with non-CMO providers if the enrollee's request is authorized by the CMO. Instances where the enrollee's request for a non-CMO provider is warranted include all of the following:

1. When the CMO does not have the capacity to meet the identified needs of its enrollees.

2. When the CMO does not have the specialized expertise, specialized knowledge or appropriate cultural diversity in its network of providers.

3. When the CMO cannot meet the enrollee's need on a timely basis.

4. When transportation or physical access to the CMO providers causes an undue hardship to the enrollee.

(e) Offer each enrollee the opportunity to participate in the monitoring and improvement of services in the enrollee's care plan.

(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:

(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.

(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.

(c) Comply with the standards for quality of services included in the CMO's contract with the department in all of the following areas:

1. Availability of services and adequacy of the CMO's provider network.

2. Continuity and coordination of care.

3. Coverage and authorization of services.

4. Provision of information to enrollees.

5. Protection of enrollee rights, including processes for protecting confidentiality and for acting on and resolving grievances and appeals.

6. Mechanisms to detect and correct both underutilization and overutilization of services.

(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:

1. Identification of performance goals, specific to the needs of the CMO's enrollees, including any goals specified by the department.

2. Identification of objective and measurable indicators of whether the identified goals are being achieved, including any indicators specified by the department.

3. Identification of timelines within which goals for improvement will be achieved.

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.

5. A description of the process the CMO will use to monitor and act on the results and feedback received.

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.

(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:

1. Measuring performance.

2. Implementing system interventions.

3. Evaluating the effectiveness of the interventions.

4. Planning for sustained or increased improvement in performance, based on the findings of the evaluation.

(f) Report all data required by the department related to standardized measures of performance, in the timeframes and format specified by the department.

(g) Cooperate with the department in evaluating outcomes and in developing and implementing plans to sustain and improve performance.

(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.

(6)   Option for enrollee self-management of service funding.

(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) .

(b) On or before December 31, 2002, the department may approve the CMO plan for self-directed support only if:

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.

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.

(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:

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.

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:

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.

b. Identify and recruit one or more individuals to provide the assistance needed by the enrollee.

c. Assist the enrollee to develop skills and knowledge needed to participate more fully in self-managing service funding.

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.

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.

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) .

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.

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.

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.

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:

a. The health and safety of the enrollee and other people are not significantly threatened.

b. The enrollee's expenditures are consistent with the budget established under subd. 5. and the plan established under subd. 6.

c. Safeguards are in place to ensure that the conflicting interests of other people are not taking precedence over the desires and interests of the enrollee.

9. If the self-managed expenditures of CMO enrollees are less than the amounts budgeted under subd. 5. , the savings are used only for services and supports consistent with the long-term care outcomes of enrollees, as identified under sub. (2) (e) 2. Savings shall not be used for administrative costs of a CMO.

10. The self-managed supports budget for an enrollee is not reduced in a subsequent year solely because the enrollee did not expend the full amount budgeted in a given year. Each year's budget is based on a re-assessment of needs and identified long-term care outcomes under subd. 5.

11. The CMO has in place policies and procedures under which the enrollee can make or authorize payments to providers and receive timely information on expenditures made and budget status.

12. The policies and procedures under subd. 11. include mechanisms for assuring compliance with requirements for the deduction and payment of payroll taxes and for providing legally mandated fringe benefits for individuals employed by the enrollee and makes assistance available to the enrollee for all of the following employment-related tasks:

a. Recruiting.

b. Screening.

c. Interviewing.

d. Hiring and firing.

e. Setting the level of wages.

f. Setting workers tasks and hours.

g. Authorizing and making payment for services delivered.

h. Setting the level of benefits, if any, to be provided in addition to requisite state and federal payroll benefits, such as vacation, sick leave or health insurance.

i. Assistance in procuring additional optional employee benefits.

j. Training workers.

k. Assessing member liability.

L. Supervising and disciplining workers.

m. Arranging back-up workers or services.

13. The CMO has policies and procedures under which the CMO may restrict the level of self-management of service funding exercised by an enrollee or for increasing the level of involvement of the case management team where the team finds any of the following:

a. The health and safety of the enrollee or another person is threatened.

b. The enrollee's expenditures are inconsistent with the budget established under subd. 5. and the plan established under subd. 6.

c. The conflicting interests of another person are taking precedence over the desires and interests of the enrollee.

d. Funds have been used for illegal purposes.

e. Negative consequences have occurred under other policies approved by the department.

14. The CMO informs each enrollee whose level of self-management of service funding is restricted under subd. 13. about what actions by the enrollee will result in removal of the restrictions.

15. The CMO informs the enrollee whose level of self-management of service funding is restricted under subd. 13. about 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 any limit on the level of self-management.

16. The CMO has policies and procedures in place related to self-management of service funding of an enrollee under guardianship that include all of the following:

a. Training for guardians to assist them in learning and respecting enrollees' preferences and goals.

b. Assistance to enrollees and their guardians in building the enrollees' skills in the area of self-determination.

c. Periodic re-assessment of enrollees' competency to exercise rights directly and assistance to enrollees in attaining or regaining rights the CMO believes they are competent to exercise.

History: Cr. Register, October, 2000, No. 538 , eff. 11-1-00; CR 04-040 : am. (4) (c) 5. Register November 2004 No. 587 , eff. 12-1-04.

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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1