Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter IV - Family Care Benefit; Delivery Through Care Management Organizations (CMOs) › Section DHS 10.44 - Standards for performance by CMOs

Current through June 24, 2024
(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 an interview with the enrollee and that comprehensively assess and
				  identify all of the following:
Note:
Par. (e) (intro.) is amended by CR
					 21-081 effective upon the termination of the Appendix K: Emergency Preparedness
					 and Response and COVID-19 Addendum to the 1915 (c) Family Care program waiver,
					 to read:
(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.