Terms & Definitions
Administrative Law Judge – An official who conducts a State Fair Hearing to resolve a dispute between a member and his or her Managed Care Organization (MCO).
Advance Directive – A written statement of a person’s wishes about medical treatment used to ensure medical staff carry out those wishes should the person be unable to communicate his or her wishes. There are different types of advance directives and different names for them. Living will, power of attorney for health care and do-not-resuscitate (DNR) order are examples of advance directives.
Advocate – Someone who helps members make sure the MCO is addressing their needs and outcomes. An advocate may help a member work with the MCO to informally resolve disputes and may also represent a member who decides to file an appeal or grievance. An advocate might be a family member, friend, attorney, ombudsman or any other person willing to represent a member.
Aging and Disability Resource Center (ADRC) – Service centers that provide information and assistance on all aspects of life related to aging or living with a disability. The ADRC is responsible for handling enrollment and disenrollment in the Family Care program.
Appeal – A request for review of a decision. Members can file an appeal when they want the MCO to change a decision their care team made. Examples of this would be when the team decides to stop or reduce a service the member is currently receiving, deny a covered service the member requests or does not pay for a covered service.
Assets – Assets include, but are not limited to, motor vehicles, cash, checking and savings accounts, certificates of deposit, money market accounts and cash value of life insurance. The amount of assets a person has is used in part to determine eligibility for Medicaid. An individual must be eligible for Medicaid to be in Family Care.
Authorized Representative – A person who has the legal authority to make decisions for a member. An authorized representative may be court-appointed, a person's guardian or a person designated as the member’s power of attorney for health care.
Benefit Package – Services that are available to Family Care members. These include, but are not limited to, personal care, home health, transportation, medical supplies and nursing care. The services a member receives must be pre-authorized by the member’s care team and listed in the member’s care plan.
Care Plan – An ongoing plan that documents the member’s personal experience and long-term care outcomes, needs, preferences, and strengths. The plan identifies the services and supports the member receives from family or friends and the authorized services the MCO will provide. The member is central to the care planning process. The care team and member meet regularly to review the member’s care plan.
Care Team – Every Family Care member is assigned a care team. The member is a central part of his or her team. The team includes the member, a social worker/care manager and a registered nurse. Members can choose anyone else they want involved on their care team, such as a family member or friend. Other professionals such as an occupational or physical therapist or mental health specialist may be involved, depending on the member’s needs. The care team works with members to assess needs, identify desired outcomes and create care plans. The team authorizes, coordinates and monitors services.
Choice – The Family Care program supports a member’s choice when receiving services. Choice means members have a say in how and when care is provided. Choice also means members are responsible for helping their care team identify services that are cost-effective. Members can also choose to direct one or more of their services by using the self-directed supports (SDS) option.
Cost Share – A monthly amount that some members may have to contribute toward the cost of their services. Cost share is based on income and is determined by the Income Maintenance Agency. Individuals must pay their cost share every month to remain eligible for Medicaid and Family Care.
Cost-Effective – The option that effectively supports the member’s identified long-term care outcome at a reasonable cost and effort. The member and the care team use the Resource Allocation Decision (RAD) process to determine ways to support the member’s long-term care outcomes. Then the member and the team look at the options and choose the most cost-effective (not necessarily the least expensive) way to support the member’s outcomes.
Department of Health Services (DHS) – The State of Wisconsin agency that runs Wisconsin’s Medicaid programs, including Family Care.
DHS Review – A review of a member’s grievance or appeal by the Department of Health Services (DHS). DHS works with MetaStar to review grievances and appeals. MetaStar reviews member concerns and tries to come up with informal solutions. A DHS review will not lead to a decision.
Disenroll/Disenrollment – The process of ending a person’s membership in Family Care. A member can choose to disenroll from Family Care at any time. The MCO is required to disenroll a member in certain situations. For example, the MCO would disenroll a member if he or she loses eligibility for Medicaid or permanently moves out of state.
Division of Hearings and Appeals (DHA) – The State of Wisconsin agency that hears Medicaid appeals for Family Care. Administrative Law Judges with this Division conduct State Fair Hearings when a member files an appeal. This division is independent of the MCO and DHS.
Enroll/Enrollment – Enrollment in Family Care is voluntary. To enroll, individuals should contact their local Aging and Disability Resource Center (ADRC). The ADRC determines whether an individual is functionally eligible for Family Care. The Income Maintenance Agency determines whether an individual is financially eligible for Medicaid and Family Care. If the individual is eligible and wants to enroll in Family Care, he or she must complete and sign an enrollment form.
Estate Recovery – The process where the state of Wisconsin seeks repayment for costs of Medicaid services when the individual receives Medicaid-funded long-term care. The state recovers money from an individual’s estate after the person and his or her spouse dies. The money recovered goes back to the Medicaid program to be used to care for other Medicaid recipients.
Expedited Appeal – A process members can use to speed up their appeal. Members can ask the MCO to expedite their appeal if they think waiting the standard amount of time could seriously harm their health or ability to perform daily activities.
Family Care – A long-term care program for frail elders, adults with developmental/intellectual disabilities and adults with physical disabilities. Family Care provides cost-effective, comprehensive and flexible services tailored to each member’s needs. The program strives to foster members’ independence and quality of life, while recognizing the need for interdependence and support.
Financial Eligibility – Financial eligibility means eligibility for Medicaid. The Income Maintenance agency looks at a person’s income and assets to determine whether he or she is eligible for Medicaid. An individual must be eligible for Medicaid to be in Family Care.
Functional Eligibility – The Wisconsin Long Term Care Functional Screen determines whether a person is functionally eligible for Family Care. The Functional Screen collects information on an individual’s health condition and need for help in such things as bathing, getting dressed and using the bathroom.
Grievance – An expression of dissatisfaction about care or services or other general matters. Subjects for grievances include quality of care, member rights and relationships between the member and his or her care team.
Guardian – The court may appoint a guardian for an individual if the person is unable to make decisions about his or her own life.
IDT, or Interdisciplinary Team, also known as the 'care team' – Defines the member's desired outcomes and creates the individual service plan. The IDT includes the member, a registered nurse, a social worker (social services coordinator) and any friends or family that the member chooses.
IDT Staff – Include, at a minimum, a registered nurse and social worker (social services coordinator) who work with the member and support the member in achieving his or her desired outcomes.
Income Maintenance Agency (formerly known as Economic Support Agency) – Staff from the Income Maintenance Agency determine an individual’s financial eligibility for Medicaid, Family Care and other public benefits.
ISP, or Individual Service Plan – The plan developed by the care team, including the member. The ISP is based on information from the ADRC and through the MCO's initial assessment of the member's needs. The MCO will contact the member within three calendar days of enrollment to develop an initial ISP.
Level of Care – Refers to the amount of help an individual needs to perform daily activities. Members must meet either a “nursing home” level of care or a “non-nursing home” level of care to be eligible for Family Care. The services available to members depend on their level of care.
Long-Term Care (LTC) – A variety of services that people may need as a result of a disability, getting older or having a chronic illness that limits their ability to complete daily activities. This includes activities such as bathing, getting dressed, making meals and going to work. Long-term care can be provided at home, in the community or in various types of facilities, including nursing homes and assisted-living facilities.
Long-Term Care Outcome – A situation, condition or circumstance that a member or the care team identifies that maximizes a member’s highest level of independence. During the assessment, care teams work with members to assess their physical health needs and ability to perform daily activities. The care team uses this information to determine a member’s long-term care outcomes. The MCO authorizes services based on long-term care outcomes.
Outcomes also include clinical and functional outcomes. A clinical outcome relates to a member’s physical, mental or emotional health. An example of a clinical outcome is being able to breathe easier. A functional outcome relates to a member’s ability to do certain tasks. An example of a functional outcome is being able to walk down stairs.
Managed Care Organization (MCO) – The agency that operates the Family Care program.
Medicaid – A medical and long-term care program operated by the Wisconsin Department of Health Services. Medicaid is also known as “Medical Assistance,” “MA,” and “Title 19.” Family Care members must meet Medicaid eligibility requirements to be a member.
Medicare – The Federal health insurance program for people age 65 or older, some people under age 65 with certain disabilities and people with end-stage renal disease (permanent kidney failure requiring dialysis or kidney transplant). Medicare covers hospitalizations, physician services and prescription drugs.
Member – A person who meets functional and financial eligibility criteria and enrolls in Family Care.
Member Rights Specialist – An MCO employee who helps and supports members in understanding their rights and responsibilities. The Member Rights Specialist also helps members understand the grievance and appeal processes and can assist members who wish to file a grievance or appeal.
MetaStar – The agency that the Wisconsin Department of Health Services (DHS) works with to review requests of grievances and appeals and conduct independent quality reviews of MCOs.
Non-Nursing Home Level of Care – Members who are at this level of care have some need for long-term care services, but are not eligible to receive services in a nursing home. A more limited set of services is available at this level of care.
Notice of Action – A written notice from the MCO explaining a specific change in service and the reason(s) for the change. The MCO must send a member a Notice of Action if the MCO denies his or her request for a covered service, refuses to pay for a covered service or plans to stop or reduce a service.
Notification of Appeal Rights – A written notice sent to members explaining their options for filing an appeal. MCOs must send a notification of appeal rights to members if the MCO did not provide services in a timely way or did not meet the deadlines for handling an appeal. MCOs may also send this notice when members do not like their care plans because it does not support their long-term care outcomes or requires members to accept care they do not want. Income Maintenance Agencies send members a notification of appeal rights when members lose financial or functional eligibility for Family Care.
Nursing Home Level of Care – Members who are at this level of care have needs that are significant enough that they are eligible to receive services in a nursing home. A very broad set of services is available at this level of care.
Ombudsman – A person who investigates reported concerns and helps members resolve issues. Disability Rights Wisconsin provides ombudsman services to potential and current Family Care members under age 60. The Board on Aging and Long Term Care provides ombudsman services to potential and current members ages 60 and older.
Personal Experience Outcomes – The goals the member has for his or her life. One member’s personal experience outcome might be being healthy enough to enjoy visits with her grandchildren, while another member might want to be independent enough to live in his own apartment.
Power of Attorney for Health Care – A legal document people can use to authorize someone to make specific health care decisions on their behalf in case they ever become unable to make those decisions on their own.
Prior Authorization (Prior Approval) – The care team must authorize services before a member receives them (except in an emergency). If a member gets a service, or goes to a provider outside of the network, the MCO may not pay for the service.
Provider Network – Agencies and individuals the MCO contracts with to provide services. Providers include attendants, personal care, supportive home care, home health agencies, assisted living care facilities, and nursing homes. The care team must authorize the member’s services before the member can choose a provider from the directory.
Residential Services – Residential care settings include adult family homes (AFHs), community-based residential facilities (CBRFs), residential care apartment complexes (RCACs) and nursing homes. The member’s care team must authorize all residential services.
Resource Allocation Decision (RAD) Process – A tool a member and his or her care team use to help find the most effective and efficient ways to meet the member’s needs and support his or her long-term care outcomes.
Room and Board – The portion of the cost of living in a residential care setting related to rent and food costs. Members are responsible for paying their room and board expenses.
Self-Directed Supports (SDS) – SDS is a way for members to arrange, purchase and direct some of their long-term care services, providing them greater responsibility, flexibility and control over service delivery. With SDS, members can choose to have control over and responsibility for their own budget for services and may have control over their providers including responsibility for hiring, training, supervising and terminating their own direct care workers. Members can choose to self-direct one or more of their services.
Service Area – The geographic area where a member must reside in order to enroll and remain enrolled in Family Care.
State Fair Hearing – A hearing held by an Administrative Law Judge who works for the Wisconsin Division of Hearings and Appeals. Members may file a request for a State Fair Hearing when they want to appeal a decision made by their care team. Members may also ask for a State Fair Hearing if they filed an appeal with their MCO and were unhappy with the MCO’s decision. Notices of Action and notifications of appeal rights give members information on how to file a request for a State Fair Hearing.