1. (1) Covered services.

   1. (a) Definitions. In this section:

      1. 1. “Care coordinator” means an individual who meets the criteria under s. DHS 105.525 (3).
      2. 2. “Employee of the child care coordination provider” means a qualified professional or care coordinator employed by, or under contract with, a child care coordination provider certified under s. DHS 105.525.
      3. 3. “Qualified professional” means an individual who meets the criteria under s. DHS 105.525 (2).

   2. (b) General.

      1. 1. Child care coordination services covered by MA are services described in this section that are provided by an employee of the child care coordination agency to help a member and, when appropriate, the member’s family, gain access to needed medical, social, educational, and other services identified during the assessment.
      2. 2. Child care coordination services are available as an MA benefit to eligible members per s. 49.45 (44), Stats.
   3. (c) Assessment. An assessment of a member’s strengths and needs is a covered child care coordination service. The assessment shall be performed by an employee of the child care coordination agency. The assessment shall be completed in writing and shall be reviewed and finalized in a face-to-face contact with the member. The employee and member must sign the finalized assessment. All assessments performed shall be reviewed and signed by a qualified professional under s. DHS 105.525. The assessment shall be performed with the assessment criteria developed and approved by the department.

   4. (d) Care planning.

      1. 1. Development of an individualized plan of care for a member is a covered child care coordination service when performed by a qualified professional.
      2. 2. The member’s individualized written plan of care shall be developed with the member and, to the maximum extent possible, in collaboration with the family or other supportive persons.
      3. 3. The plan of care shall be signed and dated by the member, qualified professional, and care coordinator.
      4. 4. The plan of care shall be updated by the qualified professional in consultation with the care coordinator when necessary or appropriate, and with the member at least every 60 days during the child’s first year of life and a minimum of every 180 days thereafter. All updates shall be made in writing and signed by the member, qualified professional, and care coordinator.

      5. 5. The plan of care shall include all of the following:

         1. a. The member’s strengths and needs and possible services which will reduce the probability of adverse outcomes.
         2. b. All possible needed services related to the needs identified in the assessment, regardless of funding source.
         3. c. Identification and prioritization of all needs found during the assessment, with an attached copy of the assessment under par. (c).
         4. d. Identification and prioritization of all services to be arranged for the member by the care coordinator under par. (c) and the names of the service providers including medical providers.
         5. e. A description of the member’s informal support system, including collaterals as defined in par. (e) 1., and any activities to strengthen it.
         6. f. Identification of individuals who participated in the development of the plan of care.
         7. g. Arrangements for various services to be made available to the member, the frequency of those services, and the expected outcome for each service.
         8. h. Documentation of unmet needs and gaps in service.
         9. i. Responsibilities of the family and child.

   5. (e) Ongoing care coordination.

      1. 1. In this paragraph, “collaterals” has the meaning provided in s. DHS 107.34 (1) (e) 1.

      2. 2. Ongoing coordination is a covered child care coordination service when performed by an employee of the child care coordination provider. The care coordinator shall confirm whether the services referred were provided to the member, and whether the services provided were consistent with the goals and objectives of the member’s care plan. The amount of service provided shall be commensurate with the specific factors addressed in the plan of care and the overall level of need. Ongoing care coordination services include any of the following:

         1. a. Information and resources to educate the members and their families about needed services and supports identified in the assessment and care plan. This may include providing information and resources to the member on the referral resource and how it supports goals from the care plan, and ensuring they have the necessary support, resources, and understanding to access and navigate the resources being provided.
         2. b. Face-to-face and phone contacts with members and their families for the purpose of determining if arranged services have been received and are effective. This shall include reassessing needs and revising the written plan of care. Face-to-face and phone contact with collaterals are included for the purposes of mobilizing services and support, advocating on behalf of a specific eligible member, informing collateral of member needs and the goals and services specified in the care plan and coordinating services specified in the care plan. Covered contacts also include case specific coordination and collaboration between qualified professionals and paraprofessional care coordinator staff regarding the needs of a specific member. All billed contacts with a member and their family, collateral contacts, and staff collaboration related to the member shall be documented in the member child’s care coordination file.
         3. c. Recordkeeping documentation necessary and sufficient to maintain adequate records of services provided to the member. This may include updating care plans, making notes about the member’s compliance with program activities in relation to the care plan, maintaining copies of written correspondence to and for the member, noting of all contacts with the member and collateral, and preparation of required reports. All plan of care management activities shall be documented in the member’s record including the date of service, the person contacted, the purpose and result of the contact and the amount of time spent. A child care coordination provider shall not bill for recordkeeping activities if there was no member contact during the billable month.

2. (2) Limitations.

   1. (a) Reimbursement for assessment and development of a care plan shall be limited to no more than one each for a member per 365 days, regardless of any change in provider during that span.
   2. (b) Reimbursement of a provider for on-going child care coordination provided to a member shall be limited to one claim for each member per month and only after the provider has had contact with the member during the month for which services are billed.
   3. (c) Child care coordination is available to a member as an inpatient in a hospital only to the extent that it is not included in the usual reimbursement to the facility, such as coordinating housing, supplies, or intervention services for the member upon discharge.
   4. (d) A child care coordination service provider shall not terminate provision of services to a member it has agreed to provide services for unless the member initiates or agrees to the termination. If services are terminated, the termination shall be documented in writing and the member shall sign the statement to indicate agreement. If the provider cannot contact a member in order to obtain a signature for the termination of services, the provider will document the reason in the member’s file as well as all attempts to contact the member. Nothing in this paragraph shall be construed to limit a member’s free choice to seek services from another provider.
   5. (e) When services are provided to multiple members in the same household, a provider may only bill for the actual time spent providing care coordination to each specific member.

3. (3) Non-covered services. All of the following services are not covered as child care coordination services:

   1. (a) Services listed in s. DHS 107.34 (3) (a) to (c) and (f) to (L).
   2. (b) Care coordination and monitoring not based on the plan of care.
   3. (c) Care coordination and monitoring that are not reasonable and necessary to improve child health outcomes.
   4. (d) General classroom instruction and programming commensurate to that licensed or administered by the department of public instruction.
   5. (e) Any other service that is a covered service under this chapter and which is provided by an MA certified or certifiable provider.
   6. (f) Any services that constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs.

History

History: EmR2421: emerg. cr., eff. 1-6-25; CR 25-004: cr. Register September 2025 No. 837, eff. 10-1-25; renum. (1) (b) to (d) to (1) (c) to (e) and correction in (1) (b) 1., (d) 5. d., (3) (a), (c), (d) 5. c. to e., (e), (f) under s. 13.92 (4) (b) 1., Stats., Register September 2025 No. 837.