Wis. Admin. Code DHS § DHS 107.28

Current through December 30, 2024

Section DHS 107.28 - Health maintenance organization and prepaid health plan services

(1) COVERED SERVICES.

(a)HMOs.

1. Except as provided in subd. 2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covered services at the time the medicaid HMO contract becomes effective with the exception of the following:

a. EPSDT outreach services;

b. County transportation by common carrier;

c. Dental services; and

d. Chiropractic services.

2. The department may permit an HMO to provide less than comprehensive coverage, but only if there is adequate justification and only if commitment is expressed by the HMO to progress to comprehensive coverage.

(b)Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.

(c)Family care benefit . A care management organization under contract with the department to provide the family care benefit under s. DHS 10.41 shall provide those MA services specified in its contract with the department and shall meet all applicable requirements under ch. DHS 10.

(2) CONTRACTS. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall:

(a) Specify the contract period;

(b) Specify the services provided by the contractor;

(c) Identify the MA population covered by the contract;

(d) Specify any procedures for enrollment or reenrollment of the recipients;

(e) Specify the amount, duration and scope of medical services to be covered;

(f) Provide that the department may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed under the contract;

(g) Provide that the department may audit and inspect any of the contractor's records that pertain to services performed and the determination of amounts payable under the contract and stipulate the required record retention procedures;

(h) Provide that the contractor safeguards recipient information;

(i) Specify activities to be performed by the contractor that are related to third-party liability requirements; and

(j) Specify which functions or services may be subcontracted and the requirements for subcontracts.

(3) OTHER LIMITATIONS. Contracted organizations shall:

(a) Allow each enrolled recipient to choose a health professional in the organization to the extent possible and appropriate;

(b)

1. Provide that all medical services that are covered under the contract and that are required on an emergency basis are available on a 24-hour basis, 7 days a week, either in the contractor's own facilities or through arrangements, approved by the department, with another provider; and

2. Provide for prompt payment by the contractor, at levels approved by the department, for all services that are required by the contract, furnished by providers who do not have arrangements with the contractor to provide the services, and are medically necessary to avoid endangering the recipient's health or causing severe pain and discomfort that would occur if the recipient had to use the contractor's facilities;

(c) Provide for an internal grievance procedure that:

1. Is approved in writing by the department;

2. Provides for prompt resolution of the grievance; and

3. Assures the participation of individuals with authority to require corrective action;

(d) Provide for an internal quality assurance system that:

1. Is consistent with the utilization control requirements established by the department and set forth in the contract;

2. Provides for review by appropriate health professionals of the process followed in providing health services;

3. Provides for systematic data collection of performance and patient results;

4. Provides for interpretation of this data to the practitioners; and

5. Provides for making needed changes;

(e) Provide that the organization submit marketing plans, procedures and materials to the department for approval before using the plans;

(f) Provide that the HMO advise enrolled recipients about the proper use of health care services and the contributions recipients can make to the maintenance of their own health;

(g) Provide for development of a medical record-keeping system that:

1. Collects all pertinent information relating to the medical management of each enrolled recipient; and

2. Makes that information readily available to member health care professionals;

(h) Provide that HMO-enrolled recipients may be excluded from specific MA requirements, including but not limited to copayments, prior authorization requirements, and the second surgical opinion program; and

(i) Provide that if a recipient who is a member of an HMO or other prepaid plan seeks medical services from a certified provider who is not participating in that plan without a referral from a provider in that plan, or in circumstances other than emergency circumstances as defined in 42 CFR 434.30, the recipient shall be liable for the entire amount charged for the service.

Wis. Admin. Code Department of Health Services DHS 107.28

Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (1) (c), Register, October, 2000, No. 538, eff. 11-1-00; correction in (1) (c) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.