Wis. Admin. Code Department of Health Services DHS 10.45 - Operational requirements for CMOs
(1) GOVERNING BOARD.
A care management organization shall have a governing board that reflects the
ethnic and economic diversity of the geographic area served by the CMO. At
least one-fourth of the members of the governing board shall be older persons
or persons with physical or developmental disabilities or their family members,
guardians or other advocates who are representative of the CMO's
enrollees.
(2) OPEN ENROLLMENT.
(a) Except as provided in s.
DHS
10.36(2), a CMO shall conduct a
continuous open enrollment period, accepting enrollment of any member of its
target population who is enrolled by an aging and disability resource center
serving the area of the CMO, without regard to life situation, health or
disability status or cost sharing requirements.
(b) A CMO may not disenroll any enrollee
except under circumstances specified in its contract with the department and
the express approval of the department, unless the enrollee has requested to be
disenrolled. When a CMO requests department approval to disenroll an enrollee,
the CMO shall refer the enrollee to the resource center for counseling under s.
DHS 10.23(2)
(j). A CMO may not encourage any enrollee to
disenroll. This paragraph shall be suspended until the first day of the month
following the end of the emergency period defined in subsection (1) (B) of
section 1135 (g) of the Social Security Act,
42 USC
1320b-5(g) (1) (B), and
declared by the United States Secretary of Health And Human Services in
relation to the COVID-19 pandemic.
Note: Par. (b) is amended by CR 21-081 eff. the first day of the month after the emergency period, as defined in section 1135 (g) (1) (b) of the Social Security Act, 42 USC 1320b-5(g) (1) (B) and declared in response to the COVID-19 pandemic, ends, to read:
(b) A CMO may not disenroll any enrollee
except under circumstances specified in its contract with the department and
the express approval of the department, unless the enrollee has requested to be
disenrolled. When a CMO requests department approval to disenroll an enrollee,
the CMO shall refer the enrollee to the resource center for counseling under s.
DHS 10.23(2)
(j). A CMO may not encourage any enrollee to
disenroll.
(3) SERVICE TO
PRIVATE PAY INDIVIDUALS. The CMO shall provide, on a fee-for-service basis,
case management and other services to private pay individuals as necessary to
meet the requirements specified in s.
DHS
10.37.
(4)
REPORTING AND RECORDS.
(a)
The department shall require each CMO to report information as the department
determines necessary, including information needed for all of the following:
1. Determination of whether the CMO is
meeting minimum quality standards, including adequate long-term care outcomes
for its enrollees.
2. Determination
of the extent to which the CMO is improving its performance on measurable
indicators identified by the CMO in its current quality improvement
plan.
3. Determination of whether
the CMO is meeting the requirements of its contract with the
department.
4. Determination of the
adequacy of the CMO's fiscal management and financial solvency.
5. Evaluation of the effects for enrollees
and cost-effectiveness of providing the family care benefit.
(b) A CMO shall submit to the
department all reports and data required or requested by the department, in the
format and timeframe specified by the department.
(5) CONFIDENTIALITY AND EXCHANGE OF
INFORMATION. No record, as defined in s.
19.32(2),
Stats., of a CMO that contains personally identifiable information, as defined
in s. 19.62(5),
Stats., concerning a current or former enrollee may be disclosed by the CMO
without the individual's informed consent, except as follows:
(a) A CMO shall provide information as
required to comply with s.
16.009(2) (p)
or 49.45(4),
Stats., or as necessary for the department to administer the family care
program under ss. 46.2805 to
46.2895, Stats.
(b) Notwithstanding ss.
48.78(2) (a),
49.45(4),
49.83,
51.30,
51.45(14) (a),
55.22,
146.82,
252.11(7),
253.07(3) (c)
and 938.78(2) (a),
Stats., a CMO may exchange confidential information about a client without the
informed consent of the client, in the county of the CMO, if necessary to
enable the CMO to perform its duties or to coordinate the delivery of services
to the client, as authorized under s.
46.21(2m) (c),
46.215(1m),
46.22(1) (dm),
46.23(3) (e),
46.283(7),
46.2895(10),
51.42(3) (e) or
51.437(4r) (b),
Stats.
Notes
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