Section DHS 10.43 - CMO certification standards If an organization applies for a contract to operate a CMO, the department shall determine whether the organization meets the requirements of s. 46.284 (2) and (3), Stats., and all of the following standards:
(1) CASE MANAGEMENT CAPABILITY. Each organization applying to operate a CMO shall demonstrate to the department that it has expertise in determining and arranging for services and supports to meet the needs of its target population. Demonstration of this expertise includes evidence that the organization, a subcontractor, or both, has all of the following:(a) A sufficient number of qualified and competent staff to meet case management standards under s. DHS 10.44.(b) Thorough knowledge of local long-term care and other community resources.(c) Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into individual service plans.(d) Strong linkages with systems and services that are not directly within the scope of the CMO's responsibility but that are important to the organization's target population, including primary and acute health care services, and the capacity to arrange for those services to be made available to its enrollees.(e) Mechanisms to coordinate services internally and with services available from community organizations and other social programs.(f) Thorough knowledge of employment opportunities and barriers for the organization's target population.(g) Thorough knowledge of methods for promoting and supporting the use of mechanisms under which individuals direct and manage their own service funding.(2) ADEQUATE AVAILABILITY OF PROVIDERS. Each organization applying to operate a CMO shall demonstrate to the department that it has adequate availability of qualified providers with the expertise and ability to serve its target population in a timely manner. To demonstrate an adequate availability of qualified providers, an organization shall assure the department that it has all of the following: (a) Agreements with providers who can provide all required services in the family care benefit.(b) Appropriate provider connections to qualify providers, on a timely basis, as needed to directly reflect the specific needs and preferences of particular enrollees in its target population.(c) Agreements with a broad array of providers representing diverse programmatic philosophies and cultural orientations to accommodate a variety of enrollee preferences and needs within its target population.(d) The ability to provide services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.(e) The ability to provide an appropriate range of residential and day services that are geographically accessible to proposed enrollees' homes, families, guardians or friends.(f) Supported living arrangements of the types and sizes that meet its target population's preferences and needs and staff to coordinate residential placements who have shown capability in recruiting, establishing and facilitating placements with appropriate matching to enrollee needs.(g) The ability to recruit, select and train new service providers, including in-home providers, in a timely fashion and a program designed to retain individual providers.(h) The ability to develop residential options that meet individual needs and desired outcomes of its enrollees.(i) Mechanisms for assuring that all service providers meet required licensure, accreditation, or other quality assurance standards.(j) Mechanisms for assuring that any service provider dissatisfied with the CMO's contract requirements shall have the opportunity to request review by the department.(k) A provider network that meets the department's quantitative network adequacy standards.(3) CERTIFICATION AS A MEDICAL ASSISTANCE PROVIDER. The organization shall be certified by the department under s. DHS 105.47.(4) ORGANIZATIONAL CAPACITY. The organization shall demonstrate that it has the organizational capacity to operate a CMO, including all of the following: (a) Financial solvency and stability and the ability to assume the level of financial risk required under the contract.(b) The ability to collect, monitor and analyze data for purposes of financial management and quality assurance and improvement and to provide that data to the department in the manner required under the contract.(c) The capacity to support consumer employment, training and supervision of family members, friends and community members in carrying out services under the consumer's service plan.(5) GRIEVANCE AND APPEAL PROCESSES. The organization shall have a process for reviewing and resolving client grievances and appeals that meets the requirements under s. DHS 10.53 (2).Wis. Admin. Code Department of Health Services DHS 10.43
Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (5) Register November 2004 No. 587, eff. 12-1-04; correction in (3) made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635.Amended by, CR 23-046: cr. (2) (k) Register April 29 No. 820, eff. 5/1/2024