Wis. Admin. Code Office of the Commissioner of Insurance § Ins 57.05 - Business plan

Current through November 29, 2021

All applications for permits of a care management organization shall include a proposed business plan. In addition to the items listed in s. 648.05(2), Stats., the following information shall be contained in the business plan:

(1) ORGANIZATIONAL INFORMATION. All care management organization business plans shall include:
(a) A narrative that discusses the business environment, the strategies and tactics that will be employed to manage the business including a plan to utilize mandated care principles and targets associated with that plan, and other areas of focus, stress, change, efficiency or any other information that supports or affects the financial projections.
(b) A description of the general business model to be employed by the care management organization.
(c) A brief organizational history, providing and describing major milestones in the development of the care management organization including organizational strengths and deficits, as they relate to the ongoing delivery of the Family Care program.
(d) A description of the care management organization's governance structure, including organizing documents (e.g., articles, by-laws, mission statement, etc.), and an organizational chart that clearly demonstrates reporting lines and domains of management authority, with names of current incumbents for management positions.
(e) Information for all persons or entities who are in direct control of the care management organization, including the names, addresses and occupations of all controlling persons, directors and principal officers of the care management organization currently and for the preceding 10 years. The care management organization information shall also include the position held and target group representation, if applicable, for each member of the board of directors.
(2) GEOGRAPHICAL SERVICE AREA. The geographical service area by county including a chart showing the number of providers with locations and service areas by county. A description and the method of handling out-of-area services shall also be included.
(3) ENROLLMENT. A description of the target populations being served by the care management organization, in what proportions these target groups are currently being served, what the long range expectations of the care management organization are in serving each target group (i.e., anticipated program growth), and how historical trends or projections are similar to, or different, from program averages.
(4) PROVIDER AGREEMENTS. The extent to which any of the following are included in provider agreements and the form of any provisions that do any of the following:
(a) Permit or require the provider to assume a financial risk in the care management organization, including any provisions for assessing the provider, adjusting capitation or fee-for-service rates, or sharing in the earnings or losses.
(b) Govern amending or terminating agreements with providers.
(5) PROVIDER AVAILABILITY. A description of the care management organization's general plan for delivering care management services to its members. Differences in the delivery of this service across target groups or counties shall be described. Changes in the delivery of care management over time, either completed or anticipated shall be described.
(6) PLAN ADMINISTRATION. A summary of how administrative services are provided, including the size and qualifications of the administrative staff and the projected cost of administration in relation to capitation income. If administrative services are to be provided by a person outside the organization, the business plan shall include a copy of the contract. The contract shall include all of the following:
(a) The services to be provided.
(b) The standards of performance for the manager.
(c) The method of payment.
(d) The duration of the contract.
(e) Any provisions for modifying, terminating or renewing the contract.
(7) FINANCIAL PROJECTIONS. A summary of all of the following:
(a) Current and projected enrollment.
(b) Income from capitation payments.
(c) Other income.
(d) Expenses associated with providing services to enrollees. A budget narrative that accompanies any projections related to care management utilization shall be provided. The narrative will identify assumed staff-to-member ratios, by type of staff; historical trends and projections regarding care management utilization; explanations regarding any major changes; and unit cost trends for each time period and target group.
(e) Administrative and other costs.
(f) The estimated break even point if a loss is being projected.
(g) A summary of the assumptions made in developing projected operating results.
(8) STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS ANALYSIS. An analysis of the CMO's strengths, weaknesses, opportunities and threats, a description of the major challenges the CMO faces, both internal and external to the organization, in providing services to each target group, and the strategies it is employing, or plans to employ, to address those challenges.
(9) FINANCIAL GUARANTEES. A summary of all financial guarantees by providers, sponsors, affiliates or parents within a holding company system, or any other guarantees which are intended to ensure the financial success of the care management organization. These include hold harmless agreements by providers, stop loss insurance, or other guarantees.
(10) BUSINESS PLAN REQUIREMENTS OF THE DEPARTMENT. The business plan filed with the department pursuant to provisions in the family care contract is acceptable for the purposes of this section.


Wis. Admin. Code Office of the Commissioner of Insurance § Ins 57.05
EmR0927: emerg. cr. eff. 10-10-09; CR 09-093: cr. Register May 2010 No. 653, eff. 6-1-10.

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