Section DHS 10.42 - Certification and contracting(1) No entity may receive payment of funds for the family care benefit as a care management organization unless it is certified by the department as meeting all of the requirements of s. 46.284, Stats., and this chapter and is under contract with the department.(2)(a) To obtain and retain certification, an organization shall submit all information and documentation required by the department, in a format prescribed by the department, including comments it has obtained from each regional long-term care advisory committee in the area it proposes to serve. The department shall review and make a determination on the application within 90 calendar days of receipt of a complete application containing complete and accurate supporting documentation that the organization meets the standards under s. DHS 10.43. The department may conduct any necessary investigation to verify that the information submitted by the organization is accurate. The organization shall consent to disclosure by any third party of information the department determines is necessary to review the application.(am) For initial certifications, or when a currently certified organization will provide or arrange for the provision of services to new eligibility groups, the organization shall submit to an onsite readiness review which will assess all of the following:1. Operations and administration, including all of the following: a. Administrative staffing and resources.b. Delegation and oversight of entity responsibilities.c. Enrollee and provider communications.d. Grievance and appeals.e. Member services and outreach.f. Provider network management.g. Program integrity compliance.2. Service delivery, including all of the following:a. Case management/care coordination/service planning.3. Financial management, including all of the following:a. Financial reporting and monitoring.4. Systems management, including all of the following:b. Encounter data and enrollment information management.(b) If the department denies CMO certification for the organization, the department shall provide written notice to the organization that clearly states the reasons for the denial and describes the manner by which the organization may appeal the department's decision.(3) If an organization applying to operate a CMO meets standards for certification under s. 46.284 (2) and (3), Stats., and s. DHS 10.43, the department shall certify the organization as meeting the requirements. Certification by the department does not bind the department to contracting with the organization to operate a CMO. The department may contract with a certified organization to operate a CMO only if all of the following apply:(b) The regional long-term care advisory committee and individuals from the local target population that the organization proposes to serve have assisted the department in its review and evaluation of all applications of organizations proposing to serve a geographic area.(c) The department has determined, after considering the advice of the regional long-term care advisory committee for the geographic area, that the organization's services are needed to provide sufficient access to the family care benefit for eligible individuals.(d) Before January 1, 2003, the organization is a county or a family care district, unless any of the following applies: 1. The county and the regional long-term care advisory committee agree in writing that at least one additional care management organization is necessary or desirable.2. The governing body of a tribe or band or the Great Lakes inter-tribal council, inc., elects to operate a care management organization within the area and is certified under sub. (2).(e) After December 31, 2002, and before January 1, 2004, the organization is a county or a family care district unless any of the following applies:1. Paragraph (d) 1. or 2. applies.2. The county or family care district fails to meet requirements of s. DHS 10.43 or 10.44 or the requirements under its contract with the department.3. The department determines that the county or family care district does not have the capacity to serve all county residents who are entitled to the family care benefit in the client group or groups that the county or family care district serves and cannot develop the capacity. If this subd. 3. applies, the department may contract with an organization in addition to the county.(4) After December 31, 2003, the department may contract with counties, family care districts, the governing body of a tribe or band or the Great Lakes inter-tribal council, inc., or under a joint application of any of these, or with a private organization that has no significant connection to an entity that operates a resource center. Proposals for contracts under this subsection shall be solicited under a competitive sealed proposal process under s. 16.75 (2m), Stats., and, after consulting with the regional long-term care advisory committee for the county or counties, the department shall evaluate the proposals primarily as to the quality of care that is proposed to be provided and certify those applicants that meet the requirements specified in s. 46.284 (2) and (3), Stats., and s. DHS 10.43. The department may select certified applicants for contract and contract with the selected applicants. Note: Until July 1, 2001, the Wisconsin Legislature has authorized the Department to establish Family Care pilots in areas of the state in which not more than 29% of the state's eligible population lives. After that date, if specifically authorized and funded by the Legislature, the Department may contract with additional entities certified as meeting requirements for a CMO. The Department is required to submit, prior to November 1, 2000, a report to the Governor that describes the implementation and outcomes of the pilots and makes recommendations about further development of Family Care.
(5) The department's contracts with CMOs shall specify a range of remedies that may be taken in the event of noncompliance by the CMO with contract requirements. The remedies may include the following:(a) Suspension of new enrollment.(b) Enrollment reductions.(c) Withholding or reduction of payments.(d) Imposition of damages.(e) Appointment of temporary management of the CMO.(f) Contract termination.(6) Except as provided in this subsection, the department shall use standard contract provisions for contracting with CMOs. The provisions of the standard contract shall comply with all applicable state and federal laws and may be modified only in accordance with those laws and after consideration of the advice of the secretary's council on long-term care.(7) The department shall annually provide to the members of the secretary's council on long-term care copies of the standard CMO contract the department proposes to use in the next contract period and seek the advice of the council regarding the contract's provisions. The department shall consider any recommendations of the council and may make revisions, as appropriate, based on those recommendations. If the department proposes to modify the terms of the standard contract, including adding or deleting provisions, in contracting with one or more organizations, the department shall seek the advice of the council and consider any recommendations of the council before making the modifications.(8) Whenever the department considers an application from an organization to be certified as meeting the standards for a CMO, the department shall provide a copy of the standard resource center contract to the regional long-term care advisory committee serving the area in which an organization operates, or proposes to operate, the CMO. If the department proposes to modify the contract, including adding or deleting provisions, the department shall seek the advice of the committee and consider any recommendations of the committee prior to signing the modified contract.(9) Prior to receiving funds to provide the family care benefit, an organization shall agree to the terms of the standard CMO contract.Wis. Admin. Code Department of Health Services DHS 10.42
Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (6) (a) and (7) Register November 2004 No. 587, eff. 12-1-04; corrections in (2) (a), (3) (a), (b), (c), (d) 1., (4), (6) (b) and (8) made under s. 13.92(4) (b) 7, Stats., Register November 2009 No. 647.Amended by, CR 22-026: r. (3) (a), cons. (6) (intro.) and (a) and renum. to (6) and am., r. (6) (b) Register May 2023 No. 809, eff. 6/1/2023Amended by, CR 23-046: cr. (2) (am) Register April 29 No. 820, eff. 5/1/2024