Section 10.45. Operational requirements for CMOs.

 

(1)   Governing board. A care management organization shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the CMO. At least one-fourth of the members of the governing board shall be older persons or persons with physical or developmental disabilities or their family members, guardians or other advocates who are representative of the CMO's enrollees.

(2)   Open enrollment.

(a) Except as provided in s. DHS 10.36 (2) , a CMO shall conduct a continuous open enrollment period, accepting enrollment of any member of its target population who is enrolled by an aging and disability resource center serving the area of the CMO, without regard to life situation, health or disability status or cost sharing requirements.

(b) A CMO may not disenroll any enrollee except under circumstances specified in its contract with the department and the express approval of the department, unless the enrollee has requested to be disenrolled. When a CMO requests department approval to disenroll an enrollee, the CMO shall refer the enrollee to the resource center for counseling under s. DHS 10.23 (2) (j) . A CMO may not encourage any enrollee to disenroll.

(3)   Service to private pay individuals. The CMO shall provide, on a fee-for-service basis, case management and other services to private pay individuals as necessary to meet the requirements specified in s. DHS 10.37 .

(4)   Reporting and records .

(a) The department shall require each CMO to report information as the department determines necessary, including information needed for all of the following:

1. Determination of whether the CMO is meeting minimum quality standards, including adequate long-term care outcomes for its enrollees.

2. Determination of the extent to which the CMO is improving its performance on measurable indicators identified by the CMO in its current quality improvement plan.

3. Determination of whether the CMO is meeting the requirements of its contract with the department.

4. Determination of the adequacy of the CMO's fiscal management and financial solvency.

5. Evaluation of the effects for enrollees and cost-effectiveness of providing the family care benefit.

(b) A CMO shall submit to the department all reports and data required or requested by the department, in the format and timeframe specified by the department.

(5)   Confidentiality and exchange of information. No record, as defined in s. 19.32 (2) , Stats., of a CMO that contains personally identifiable information, as defined in s. 19.62 (5) , Stats., concerning a current or former enrollee may be disclosed by the CMO without the individual's informed consent, except as follows:

(a) A CMO shall provide information as required to comply with s. 16.009 (2) (p) or 49.45 (4) , Stats., or as necessary for the department to administer the family care program under ss. 46.2805 to 46.2895 , Stats.

(b) Notwithstanding ss. 48.78 (2) (a) , 49.45 (4) , 49.83 , 51.30 , 51.45 (14) (a) , 55.22 , 146.82 , 252.11 (7) , 253.07 (3) (c) and 938.78 (2) (a) , Stats., a CMO may exchange confidential information about a client without the informed consent of the client, in the county of the CMO, if necessary to enable the CMO to perform its duties or to coordinate the delivery of services to the client, as authorized under s. 46.21 (2m) (c) , 46.215 (1m) , 46.22 (1) (dm) , 46.23 (3) (e) , 46.283 (7) , 46.2895 (10) , 51.42 (3) (e) or 51.437 (4r) (b) , Stats.

History: Cr. Register, October, 2000, No. 538 , eff. 11-1-00; correction in (5) (b) made under s. 13.92 (4) (b) 7. , Stats., Register November 2008 No. 635 .