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
(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.
Notes
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