Definitions of Important Words

Abuse – The physical, mental, or sexual abuse of an individual. Abuse also includes treatment without consent and unreasonable confinement or restraint.

Administrative Law Judge – An official who presides at a State Fair Hearing to resolve a dispute between a member and the member’s Managed Care Organization (MCO).

Advance Directive – A written statement of a person’s wishes about medical treatment used to make sure medical staff carry out those wishes should the person be unable to communicate their 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 Team made. Examples of this would be when the Team decides to stop or reduce a service the member is currently receiving, deny a service the member requests, or not pay for a 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.

Authorized Representative – A person who has the legal authority to make decisions for a member. An authorized representative may be court appointed, a person designated as the member’s power of attorney for health care, or a person’s guardian.

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-approved by the member’s Team and listed in their care plan.

Care Plan – An ongoing plan that documents the member’s personal outcomes, needs, preferences, and strengths. The plan identifies the services and supports the member receives from family or friends, and identifies authorized services the MCO will provide. The member is central to the care plan process. The 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, and at least a care manager and a registered nurse. Members can choose anyone else they want involved on their 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 Team works with members to assess needs, define personal 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 Team identify services that are cost-effective. Members can also choose to direct some or all of their care by using the self-directed supports (SDS) option.

Cost Share or Spend Down – A monthly amount that some members may have to contribute toward the cost of their services. Cost share or spend down is based on income and is determined by the Income Maintenance agency. Individuals must pay their cost share or spend down every month to remain eligible for Medicaid.

Cost-Effective – The balance between the cost of services and the member’s personal outcomes. The member and the Team use the Resource Allocation Decision (RAD) method to determine ways to support the member’s outcomes. Then the member and the Team look at the options and choose the most efficient (not necessarily the cheapest) 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 an external organization to review grievances and appeals. The external organization 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 has 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 preside over 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 financial eligibility. If the individual is eligible and wants to enroll in Family Care, they must complete and sign an enrollment form.

Estate Recovery – The process where the State of Wisconsin seeks repayment for costs of certain long-term care services. 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.

External Review Organization – The agency that the Wisconsin Department of Health Services (DHS) works with to review requests of grievance and appeals and conduct independent quality reviews of MCOs.

Family Care – A long-term care program for frail elders, adults with developmental 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 in order to enroll 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, relationships with Team members, and member rights.

Guardian – The court may appoint a guardian for an individual if the person is unable to make decisions about his or her own life.

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.

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 do the things they need to do throughout their day. This includes such things 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.

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 in order 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.

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 the member a Notice of Action if the MCO denies a member’s request for a new service, refuses to pay for a service, or plans to stop or reduce a member’s 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 didn’t provide services in a timely way or didn’t meet the deadlines for handling an appeal. Other situations when MCOs send this notice include times when members didn’t like their care plan because it didn’t support their outcomes or requires members to accept care they didn’t 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 age 60 and older.

Personal Outcomes – Represent what is important to the member, including their goals, hopes, and dreams. These outcomes are the “results” the MCO tries to help the member achieve. One person’s outcome might be being healthy enough to enjoy visits with her grandchildren, while another person might want to be able to be independent enough to live in his own apartment.
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.

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 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. Members receive a copy of a Provider Network Directory, which lists available providers. The 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 facility facilities (CBRFs), residential care apartment complexes (RCACs), and nursing homes. The member’s Team must authorize all residential services.

Resource Allocation Decision (RAD) Method – A tool a member and his or her Team use to help find the most effective and efficient ways to meet the member’s needs and support his or her 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 their long-term care services. Members have greater responsibility, flexibility and control over service delivery. With SDS, members can choose to control their own budget for services, and may have control over their providers including hiring, training, supervising, and firing their own direct care workers. Members can choose to self-direct all or some 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 Hearing and Appeals. Members may file a request for a State Fair Hearing when they want to appeal a decision made by their 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.

Definitions of Services in the Family Care Benefit Package

Home and Community Based Waiver Service Definitions
Full definitions available upon request
Adaptive aids are controls or appliances that enable people to increase their abilities to perform activities of daily living or control the environment in which they live (including patient lifts, control switches, etc.).
Adult day care services are the provision of services for part of a day in a non-residential group setting to adults who need an enriched social or health-supportive experience or who need assistance with activities of daily living, supervision and/or protection.
1-2 bed Adult family homes are places in which the operator provides care, treatment, support, or services above the level of room and board for up to two adults.
3-4 bed Adult family homes are places where 3-4 adults who are not related to the operator reside and receive care, treatment or services above the level of room and board and that may include up to seven hours of nursing care per resident.
(CBRF) Community based residential facility is a place where 5 or more adults who are not related to the operator or administrator reside and receive care, treatment, support, supervision and training.
(RCAC) Residential care apartment complexes are services provided in a homelike, community based setting where five or more adults reside in their own living units that are separate and distinct from each other.
Case management services (sometimes called support and service coordination) are provided by a care Team. The member is the center of the Team. The Team consists of, at minimum, a registered nurse and a care manager, and may also include other professionals as appropriate to the needs of the member and family or other informal supports requested by the member.
Communication aids are devices or services needed to assist members to hear, speak or see.
Consumer education and training are services designed to help a person with a disability develop self-advocacy skills, exercise civil rights, and acquire skills needed to exercise control and responsibility over other support services.
Counseling and therapeutic resources are services to treat personal, social, behavioral, emotional, cognitive, mental health, or alcohol or other drug abuse disorders.
Daily living skills training teaches members the skills involved in performing activities of daily living, including skills intended to increase the member’s independence and participation in community life.
Day services is the provision of regularly scheduled activities in a non-residential setting (day center) to enhance social development and to develop skills in performing activities of daily living and community living.
Financial management services assist members and their families to manage service dollars or manage their personal finances.
Home delivered meals (sometimes called "meals on wheels") include the costs associated with the purchase and planning of food, supplies, equipment, labor and transportation to deliver one or two meals a day to members who are unable to prepare or obtain nourishing meals without assistance.
Home modifications are the provision of services and items to assess the need for, arrange for and provide modifications and or improvements to a member’s living quarters in order to provide accessibility or enhance safety.
Housing counseling is a service which provides assistance to a member when acquiring housing in the community, where ownership or rental of housing is separate from service provision.
Personal emergency response system (PERS) is a service that provides a direct telephonic or other electronic communications link between someone living in the community and health professionals to secure immediate assistance in the event of a physical, emotional or environmental emergency.
Prevocational services involve learning and work experiences where a member can develop general, non-job-task-specific strengths and skills that contribute to employability in paid employment in integrated, community settings.
Relocation services are the provision of services and essential items needed to establish a community living arrangement for members who are relocating from an institution or who are moving from a family home to establish an independent living arrangement.
Respite care services are services provided on a short-term basis to relieve the member’s family or other primary caregiver(s) from daily stress and care demands.
Self-directed supports (SDS) (or consumer-directed supports) is an option within Family Care that allows members to direct their own services within a service budget determined through the development of a care plan. A member can choose to self-direct some or all of the services.
Skilled nursing means the observation or care of the ill, injured, or infirm for the maintenance of health or prevention of illness that requires substantial nursing skill, knowledge, or training, or application of nursing principles based on biological, physical, and social sciences.
Specialized medical equipment and supplies are those items necessary to maintain the member’s health, manage a medical or physical condition, improve functioning or enhance independence.
Specialized transportation services assist in improving an individual's general mobility and ability to perform tasks independently and to gain access to waiver and other community services, activities and resources. Services can consist of material benefits such as tickets or other fare medium needed as well as direct conveyance of members and their attendants to destinations.
Supported employment services help members who, because of their disabilities, need intensive on-going support to obtain and maintain competitive or customized employment in an integrated work setting.
Supportive home care (SHC) includes services that directly assist members with daily activities and personal needs to meet their daily needs and to ensure adequate functioning in their home.
Vocational futures planning and support is a person-centered, team based comprehensive employment planning and support service that provides assistance to obtain, maintain or advance in employment or self-employment.