1. (1) Agency. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be any of the following:

   1. (a) A community-based health organization.
   2. (b) A community-based social services agency or organization.
   3. (c) A county, city, or combined city and county public health agency.
   4. (d) A county department of human services under s. 46.23, Stats., or social services under s. 46.215 or 46.22, Stats.
   5. (e) A family planning agency certified under s. DHS 105.36.
   6. (f) A federally qualified health center, as defined in 42 CFR 405.2401 (b).
   7. (gm) A home visiting program under 42 USC 711.
   8. (h) An independent physician association.
   9. (i) A hospital.
   10. (j) A physician’s office or clinic.
   11. (m) A rural health clinic certified under s. DHS 105.35.
   12. (n) A tribal agency health center.
   13. (o) A women, infants, and children program under 42 USC 1786.

2. (2) Qualified professionals.

   1. (a) Definition. In this subsection, “qualified professional” means any of the following:

      1. 1. A nurse practitioner licensed as a registered nurse pursuant to s. 441.06, Stats., and currently certified by the American nurses’ association, the national board of pediatric nurse practitioners and associates, or the nurses’ association of the American college of obstetricians and gynecologists’ certification corporation.
      2. 2. A nurse midwife certified under s. DHS 105.201.
      3. 3. A public health nurse meeting the qualifications of s. DHS 139.08.
      4. 4. A physician licensed under ch. 448, Stats., to practice medicine or osteopathy.
      5. 5. A physician assistant certified under ch. 448, Stats.
      6. 6. A dietitian certified or eligible for registration by the commission on dietetic registration of the academy of nutrition and dietetics with at least 2 years of community health experience.
      7. 7. A registered nurse with at least 2 years of experience in maternity nursing or community health services or a combination of maternity nursing and community health services.
      8. 8. An employee with at least a bachelor’s degree and 2 years of experience in health promotion, health advocacy, health education, case management or care coordination, child or family social work, community outreach, or child welfare or related field; or

      9. 9. A health educator with any of the following:

         1. a. A certified health education specialist credential from the National Commission for Health Education Credentialing.
         2. b. A master’s degree in health education and at least 2 years of experience in community health services.

      10. 10. A doula with at least 4 years of experience providing care coordination and any of the following:

          1. a. Certification by a department approved doula certification program.
          2. b. Experience providing doula services that is functionally equivalent to the training required under a department approved doula certification program.
      11. 11. A licensed midwife under ch. 440 subch. XIII, Stats., or a licensed nurse midwife under s. 441.15, Stats.
      12. 12. A licensed clinical social worker certified under s. 457.08 (4), Stats.

   2. (b) Required qualified professionals. To be certified to provide prenatal care coordination services that are reimbursable under MA, the prenatal care coordination agency under sub. (1) shall have on staff, either employed, under contract, or in a volunteer capacity, at least one qualified professional with all of the following:

      1. 1. At least 2 years of experience in coordinating services for at-risk or low-income women.
      2. 2. The necessary skills to supervise assessment and ongoing care coordination and monitoring.
      3. 3. Education on providing health education and nutrition counseling or at least one year of work experience providing health education and nutrition counseling.

   3. (c) Duties of a qualified professional. A qualified professional shall do all of the following:

      1. 1. Supervise tasks assigned to care coordinators.
      2. 2. Administer or review and sign each comprehensive assessment and assessment update performed.
      3. 3. Develop and sign the individualized plan of care based on the needs identified in the assessment.
      4. 4. Confer with the care coordinator regarding the member’s progress towards goals and outcomes identified in the member’s plan of care.
      5. 5. Provide health education and nutritional counseling services.
   4. (d) Division of duties for multiple qualified professionals. If a prenatal care coordination agency has on staff or under contract more than one qualified professional meeting the requirements of par. (b) 1. to 3., then any duty listed in par. (c) may be assigned to a specific qualified professional.

3. (2m) Qualifications and duties of care coordinators.

   1. (a) Qualifications. A care coordinator shall have all of the following qualifications:

      1. 1. Be trained under sub. (6) in the provision of prenatal care coordination services, and in each skill that the care coordinator is assigned under sub. (4) (k).

         Note: The reference to skills assigned under sub. (4) (k) was inadvertently left in during rulemaking. The phrase after the comma should have been struck. Corrections will be made in future rulemaking.

      2. 2. Provide documentation of required training to the prenatal care agency for the provider’s records.
      3. 3. Have the skills, education, experience and ability to fulfill the employee’s job duties listed in par. (b).
      4. 4. Be at least 18 years old.

   2. (b) Duties. A care coordinator shall do all of the following:

      1. 1. Perform tasks assigned by the qualified professional supervisor.
      2. 2. Report in writing to the qualified professional supervisor on each comprehensive assessment and assessment update administered.
      3. 3. Confer with the qualified professional supervisor regarding the member’s progress towards goals and outcomes identified in the member’s plan of care.

4. (3) Sufficiency of agency certification. Individuals employed by or under contract with an agency that is certified to provide prenatal care coordination services under this section may provide prenatal care coordination services upon the department’s issuance of certification to the agency. The agency shall do all of the following:

   1. (a) At the time of hire or contract, and at least every 3 years thereafter, conduct and document a background check for all care coordinators and qualified professionals following the procedures in s. 50.065, Stats., and ch. DHS 12.
   2. (b) Maintain a list of all persons who provide or supervise the provision of prenatal care coordination services. The list shall include the credentials of each named individual who is qualified to supervise assessment and ongoing care coordination under sub. (2) (b) and (c).
   3. (c) Report in writing to the department the name of any qualified professional hired to provide prenatal care coordination services within 10 business days of the hiring.
   4. (d) Report in writing to the department the termination of any qualified professional who provided prenatal care coordination services within 10 business days of the termination.

5. (3m) Fit and qualified determination.

   1. (a) In this subsection:

      1. 1. “Applicant” means the person seeking MA certification as a prenatal care coordination services provider.
      2. 2. “Principal” means an administrator or a person with management responsibility for the agency who owns directly or indirectly 5 percent or more of the shares or other evidences of ownership of a corporate applicant, a partner in a partnership which is an applicant, or the owner of a sole proprietorship which is an applicant.

   2. (b) An applicant may not be certified under this section unless the department determines that the applicant and any principal with the agency are fit and qualified to provide prenatal care coordination services, considering all of the following:

      1. 1. Whether the applicant or any principal with the agency have convictions for a crime involving any of the following:

         1. a. Neglect or abuse of patients.
         2. b. Assaultive behavior or wanton disregard for the health and safety of others.
         3. c. Delivery of health care services or items.
         4. d. Misappropriation, theft, or fraud.
      2. 2. Whether the applicant or any principal with the agency has a finding of abuse or neglect of a client, or misappropriation of client property under s. 146.40 (4r) (b), Stats.
      3. 3. The applicant and any principal with the agency’s financial stability, including outstanding debts or amounts due to the department or other government agencies, including unpaid forfeitures and fines, that resulted in the applicant or principal’s business, corporation, or partnership filing for bankruptcy under chapter 7 or 11 of the United States Bankruptcy Code, 11 USC 701 to 784 or 1101 to 1195.
      4. 4. Whether the applicant and any principal with the agency has experience through education or at least one year of continuous work experience in child health and family services.

6. (4) Administrative records and required documentation. To be certified to provide prenatal care coordination services under this section, the prenatal care coordination provider under sub. (1) shall comply with s. DHS 106.02 (9) and shall submit a plan of operation to the department and implement the plan, once certified. The plan of operation shall demonstrate all of the following:

   1. (a) That the provider is located in the area it will serve.
   2. (b) That the provider has a variety of techniques to identify low-income pregnant women.

   3. (c) That, at a minimum, the provider has the name, location and telephone number of all of the following resources in the area to be served:

      1. 1. Women, infants, and children (WIC) programs.
      2. 2. Maternal and child health services.
      3. 3. The county, city, or combined city and county public health agency.
      4. 4. Child day care services.
      5. 5. Mental health and substance use disorder treatment agencies.
      6. 6. The county protective service agency.
      7. 7. Domestic abuse agencies.
      8. 8. Translator and interpreter services including services for the hearing-impaired.
      9. 9. Family support services.
      10. 10. Transportation services.
      11. 10g. Food programs.
      12. 10r. Housing resources and programs.
      13. 11. MA-certified primary care and obstetric providers, including health maintenance organizations participating in the medical assistance program’s HMO program.
   4. (dm) That the provider coordinate with other health and social service agencies in the service area, including managed care providers and community resource providers, to avoid duplication of services and to facilitate coordination of prenatal care services to members.
   5. (e) That the agency has contacted in writing MA-certified primary and obstetric care providers in its area and has identified the types of services the prenatal care coordination agency provides. These contacts and this information shall be documented and the documentation retained in the agency’s administrative records.

   6. (f) That the agency has the ability and willingness to deliver services in a manner that is sensitive to the particular characteristics of the racial or ethnic group or groups with which it intends to work. Documentation of that ability shall be maintained and kept up-to-date. Documentation shall consist of one or more of the following at all times:

      1. 1. Records showing the racial and ethnic composition of the population served in the past.
      2. 2. Records showing that the agency has developed, implemented and evaluated programs specifically targeted toward the racial or ethnic group or groups.
      3. 3. Records showing that the agency has provided health care services in a geographic area where a significant percentage of the population was the same as the agency’s targeted racial or ethnic group or groups.
      4. 4. Evidence that the agency’s board or administration has a significant amount of representation from the targeted group or groups.
      5. 5. Letters of support from minority health service organizations which represent the targeted group or groups.
      6. 6. Evidence of the agency’s ability to address pertinent cultural issues such as cultural norms and beliefs, language, outreach networking and extended family relationships.
   7. (g) That the agency has the ability to arrange for supportive services provided by other funding sources such as county transportation, county protective services, interpreter services, child care services and housing. This description shall include the methods, techniques and contacts which will be used to offer and provide assistance in accessing those services.
   8. (h) That the provider has the capability to provide ongoing prenatal care coordination monitoring of pregnant MA members and to ensure that all necessary services are obtained.
   9. (i) That the provider has hired or contracted at least one qualified professional meeting the criteria in sub. (2).
   10. (j) The entire service provision process including referrals, service delivery, assessment, care planning, and follow-up activities.
   11. (k) The provider’s personnel management and training plan, as required under sub. (6).
   12. (L) The provider’s quality assurance procedures and documentation requirements.
   13. (m) That the provider has adequate resources to maintain a cash flow sufficient to cover operating expenses for 60 days.

7. (5) Member record. The prenatal care coordination agency shall maintain a confidential prenatal care coordination file for each recipient receiving prenatal care coordination services, which includes all of the following items required or produced in connection with provision of covered services under s. DHS 107.34 (1):

   1. (a) Verification of the pregnancy.
   2. (b) Completed assessment.
   3. (c) Care plan.
   4. (d) Completed consent documents for release of information.
   5. (e) A written record of all member-specific prenatal care coordination monitoring which includes the dates of service, description of service provided, the staff person doing the monitoring, the contacts made, the length of time, signature and date, and the results.

   6. (f) Documentation regarding referrals from a prenatal care coordination provider to service providers and follow-up, including all of the following:

      1. 1. The name of the referred provider.
      2. 2. The reason for referral.
      3. 3. The date the referral was made.
      4. 4. Any authorizations from the member for release of information.
      5. 5. All communication and follow-up on the referral with both the member and the referred provider.
   7. (g) All pertinent correspondence relating to coordination of the recipient’s prenatal care.

8. (6) Personnel management. The prenatal care coordination agency shall document and implement a personnel management system and training plan that includes all of the following:

   1. (a) The agency’s plan to hire, support, and train staff to provide services that are family centered and culturally appropriate.

   2. (b) If more than one qualified professional or care coordinator is employed or under contract with the agency, all of the following:

      1. 1. A process for periodically evaluating every care coordinator and qualified professional supervisor employed by or under contract with the agency in accordance with the provider’s quality assurance procedures.
      2. 2. A process for following up on all evaluations with appropriate action to ensure the employee can competently perform all assigned duties.
   3. (c) A requirement that no employee or subcontractor may be assigned any duty for which they are not trained. The prenatal care coordination agency shall provide or arrange for training of employed or subcontracted care coordinators as necessary.

   4. (d) Procedures for ensuring all qualified professionals and care coordinators receive orientation and ongoing instruction. The procedures shall include:

      1. 1. Requirements that orientation and training shall be completed by a qualified professional or care coordinator before they provide services to a member.
      2. 2. The names and titles of persons responsible for conducting orientation and training.
      3. 3. Dates of the trainings and a description of the course content and length of training.

      4. 4. Topics covered in orientation, which shall include training on all of the following, at minimum:

         1. a. The goals, mission, and priorities of the provider.
         2. b. Specific job duties specified in sub. (2m) (b).
         3. c. The functions of care coordinator by provider and how they interrelate and communicate with each other in providing services.
         4. d. Health and safety procedures for working in a home environment.
         5. e. Responding to medical and non-medical emergencies.
         6. f. Ethics, confidentiality of member information, and member rights.
      5. 5. A process for providing instruction when an evaluation of the qualified professional’s or care coordinator’s performance or competency indicates additional instruction may be needed.
   5. (e) Standards for qualified professional supervision of services rendered by a care coordinator, including the frequency and duration of supervision. When supervision reveals a failure to follow the member’s care plan, the prenatal care coordination provider agency or qualified professional shall provide counseling, education or retraining to ensure the care coordinator is adequately trained to complete their job responsibilities. In the case of prenatal care coordinators who are not employees of the prenatal care coordination provider, the plan shall specify all required training, qualifications, and services to be performed in a written care coordinator provider contract between the prenatal care coordination provider and care coordinators, and maintain a copy of that contract on file.
   6. (f) A process for documenting performance of care coordination services by care coordinators by maintaining time sheets of care coordinators which document the types and duration of services provided, by funding source.

   7. (g) A requirement that all prenatal care coordination provider staff or contractors who have or are expected to have regular and direct contact with members complete a minimum of 5 hours of annual training. Annual training shall be related to maternal and child health, case management, or similar social service continuing education, and may be provided via in-service training, conferences, workshops, continuing education, or higher education credits. This requirement shall include all of the following:

      1. 1. A process for obtaining required additional training, as identified by the supervising qualified professional.
      2. 2. A process for documenting staff completion of ongoing training requirements in the employee’s file.

9. (7) Agency closure or discharge of member.

   1. (a) Any prenatal care coordination agency that intends to close shall provide written notice to each member, the member’s legal representative, if any, the member’s attending physician and the department at least 30 days before closure.
   2. (b) The prenatal care coordination agency shall provide assistance to members in arranging for continuity of necessary services. This includes, but is not limited, to coordination with other prenatal care coordination providers to ensure necessary services identified in the care plan are sustained or initiated.

History

History: Cr. Register, June, 1994, No. 462, eff. 7-1-94; CR 03-033: am. (1) (L), (2) (a) (intro.), 1., 6. to 8. Register December 2003 No. 576, eff. 1-1-04; corrections in (1) (intro.), (2) (a) 3., (4) (intro.) and (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 25-004: am. (1) (intro.), (a) to (f), r. (1) (g), cr. (1) (gm), am. (1) (h) to (j), r. (k), (L), am. (1) (m) to (o), (2) (a) 1. to 8., renum. (2) (a) 9. to (2) (a) 9. (intro.) and am., cr. (2) (a) 9. a., b., 10. to 12., am. (2) (b), cr. (2) (c), (d), (2m), renum. (3) to (3) (intro.) and am., cr. (3) (a) to (d), (3m), am. (4) (intro.), (a), (b), (c) (intro.), 1. to 10., cr. (4) (c) 10g., 10r., r. (4) (d), cr. (4) (dm), am. (4) (e), (f) 1. to 6., (g) to (i), cr. (4) (j) to (m), am. (5) (title), (intro.), (a) to (e), renum. (5) (f) to (5) (f) (intro.) and am., cr. (5) (f) 1. to 5., (6), (7) Register September 2025 No. 837, eff. 10-1-25; correction in (1) (h), (3) (a), (3m) (a) 2., (b) 3., (6) (d) 4. b., (e) made under s. 35.17, Stats., Register September 2025 No. 837.