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Being a Full Partner

January 2010

Important information for Family Care and Family Care Partnership members or for anyone who is trying to decide whether to enroll in managed long-term care.

Welcome

If you recently made the decision to enroll in one of Wisconsin's managed long-term care program, this booklet will provide you with information about being a member. Or if you are still working with your local Aging and Disability Resource Center to determine the best program for you, this booklet can be a source of information to help you make your choice. This booklet is also intended for family members, guardians and health care professionals who are helping a member make decisions or have legal responsibility to make decisions on the member's behalf.

The Basics

Once you enroll in a managed long-term care program, you become a 'member'. The word 'member' means a person who is enrolled in a managed care organization's (MCO) Family Care or Partnership Program. The word "you" is used in this booklet to refer to a Family Care or Partnership member or potential member. MCOs operate these long-term care programs. They are agencies that provide or coordinate a wide range of health and long-term support services to people who are eligible and choose to enroll.

In Family Care and Partnership, each MCO receives a monthly payment from the State of Wisconsin for each member. The MCO then pools the money and uses it to provide individually planned services for all of its members. Sometimes members are required to pay a share of the cost of the services they receive. This is called "cost share" or "spend down." If you will have a cost share or spend down, staff from the Aging and Disability Resource Center (ADRC) will discuss this with you before you make a final decision about enrolling.

Each MCO has a member handbook (also called the Evidence of Coverage booklet in Partnership) that provides more information about MCO services and member rights. The MCO is required to give the member handbook and a list of the providers it routinely uses (provider network list) to each member. This information is to show you the whole range of services and providers available to all members. It does not mean that you can get a service that is listed just because you are a member. You and your interdisciplinary team will determine which of the available services are appropriate to support your outcomes. (See below)

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What does being a "full partner" mean?

As a member, you have a right to be a full partner in deciding what you need and want from your health and long-term support services, and in planning how those services will be provided. You have a right to:

• Participate in decisions that affect your own care.
• Choose to involve family members or other people.
• Know what different services and supports are available or could be developed. You can also suggest other services or supports that you think would meet your needs.
• Make reasonable choices about the services and providers you want, and get support from the MCO to help you make those choices.

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What managed long-term care options are available?

Family Care and Partnership are Wisconsin's flexible health and long-term care programs. Both programs are voluntary and offer you choice in where you receive services, access to a wide range of health and long-term care services, and a focus on your own goals for your health and quality of life.

Family Care provides a full range of long-term care services. Partnership, adds medical care to the long-term support services in Family Care.

These programs are not yet available in all areas of the State. Your local Aging and Disability Resource Center can tell you what programs are available in your area.

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What are outcomes, and why do they matter?

Family Care and Partnership provide a wide range of services and supports specially designed for each particular individual. One of the most important things an MCO will do is to help you identify your personal outcomes. These outcomes are the "results" the MCO try to help you get.

The general outcomes that Family Care and Partnership help members achieve are:

• I decide where and with whom I live.
• I make decisions regarding my supports and services.
• I work or do other activities that are important to me.
• I have relationships with family and friends I care about.
• I decide how I spend my day.
• I am involved in my community.
• My life is stable.
• I am respected and treated fairly.
• I have privacy.
• I have the best possible health.
• I feel safe.
• I am free from abuse and neglect.

For example, 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. You have a right to expect that your care team will work with you to design and carry out a plan that will help you move toward your own outcomes. This does not mean the MCO will always buy services to help you achieve your outcomes. The things you do for yourself, or that your family and friends do for you, will still be a very important part of any plan to help you achieve your personal outcomes.

Family Care and Partnership may not be able to help you get everything you want out of life. The MCO is responsible for providing you with supports to effectively achieve your personal outcomes. The MCO also has to consider cost-effectiveness of services and providers. Most MCOs use the Resource Allocation Decision (RAD) method as a guide in the decision making process. The RAD is a step-by-step tool you and your team will use to help determine the most effective and cost-effective way to achieve your outcomes.

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Who is involved in the planning process?

In Family Care, the people on your care team include you and anyone else you want to have involved, which could be your guardian, a family member or friend, or a professional ombudsman or advocate. It also includes at least a registered nurse and a care manager assigned by the MCO. Other professionals such as an occupational or physical therapist, or mental health specialist, may be involved, depending on your needs.

In Partnership, your care team is the same as in Family Care, but also includes a nurse practitioner, who coordinates care with your doctor.

The job of the Family Care and Partnership care team is to work with you to:

• Identify the health and long-term care outcomes you need and want.
• Develop a member-centered plan that outlines the services and other help you need to achieve those outcomes.
• Make sure the services in the plan are actually provided.
• Make sure the plan continues to work for you.

You should be involved in every part of the process, and you should get any extra help (like a reader or interpreter) you need in order to take part in the process. If you want, the care team should work with you to involve family members, friends, an advocate, or other people important to you in the planning process.

If you have a guardian or activated power of attorney for health care, that person will be involved in planning along with you, and will give the legal consent to services and will work with you and the rest of the care team to make sure that your voice is heard and respected.

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How do you and your care team decide what support you need and what personal outcomes are important to you?

The first step in planning Family Care or Partnership services is for you to tell your care team:

• What kind of life you want to live,
• Whether you want to live at home or in a different living situation, and
• What kind of support you need to live the kind of life you want.

This step is called the assessment. The assessment is an ongoing process with your team. The assessment provides the team with a clear understanding of the services needed to support your outcomes, needs and preferences.

Being a full partner in the assessment means:

• You and your care team have a face-to-face meeting to discuss your outcomes, needs and preferences. Your care team will make sure you understand the purpose of the meeting.
• If you want other people involved, your care team must support and encourage those people to be involved.
• Your care team must ask you what you want your life to be like, and what you see as your most important support needs.
• The care team will use your answers in deciding with you what personal outcomes your member-centered plan will try to achieve for you. (See the next section.)
• Even if you are already receiving some help, your care team will help you identify any needs and personal outcomes you have that are not being met.

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What should be covered in the member-centered plan?

Your care team will develop a member-centered plan for you that will help you move toward the personal outcomes that you identified in the assessment. The plan must be clear about:

• Your strengths and preferences,
• Your personal outcomes,
• What services and supports you will receive to achieve your personal outcomes,
• Who on the care team is responsible for tracking the supports related to your personal outcomes,
• How often you will meet face-to-face with your care team and identify other contacts based on your needs,
• When you and your care team will review and update your member-centered plan,
• Who is going to provide you with each service or support, and
• The things you are going to do yourself or with help from family or friends and how your care team plans to maintain and/or enhance your existing informal community supports.

The member-centered plan is an ongoing process. You will meet with your care team to see how you are doing and to evaluate if services and supports are helping you achieve your personal outcomes. The MCO must give you a copy of your plan.

Your member-centered plan can change as your needs change, which means that if you have a change in your life that affects your needs or your outcomes, you should contact your care team. When your care team knows about these changes your member-centered plan can be adjusted if needed.

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How do you and your care team balance your personal outcomes and service cost?

The MCO is responsible for helping you to achieve your personal outcomes, but also has to consider cost when deciding what services to provide. Most MCOs do this through a process called the Resource Allocation Decision (RAD) method.

The RAD method is a series of questions you and your care team will talk through to identify your personal outcomes and to match your outcomes with the right services and supports. Using this method, your care team helps you find the most effective and cost-effective way of helping you achieve your personal outcomes.

The member-centered plan should be both reasonable and effective. This means that you do not have to settle for a member-centered plan that does not help you reach your outcomes, or that gets in the way of an outcome.

However, an MCO may choose to provide a service in a less expensive way if the member-centered plan is still effective in helping you meet your individual outcomes.

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How does the State know if the MCOs are successful in helping people achieve their personal outcomes?

Talking directly with members is one way the State and the MCO can get information about how well Family Care and Partnership are helping people meet their personal outcomes. Each year the State talks with some MCO members about where they live, where they work, and the services and supports they receive.

As a member, you may be asked to have a conversation like this with a trained interviewer. It will be your decision whether or not you want to participate. The interviews take about one hour, and occur wherever the member is most comfortable, whether that is at home, at work, or even at a coffee shop or restaurant. The State and MCO will use the information gathered during these interviews to learn what services and supports are working to help support members' personal outcomes.

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How do Family Care and Partnership help you control your own services?

Family Care and Partnership strive to respect the choices of their members. For example:

• Living arrangement, daily routine and support services of your choice are examples of the general outcomes categories Family Care and Partnership are meant to support. You have a right to help define what is important to you in these specific personal outcome areas. You will work with your care team to find reasonable ways to support these outcomes. If you do not think your care plan offers reasonable supports for your personal outcomes, you can file a grievance or appeal.
• If you ask, the MCO must consider using a provider it does not usually use, if that provider would better meet your needs.
• For hands-on care or services that involve coming into your home often, the MCO will buy services from a provider you choose, including a family member, if the provider is qualified and will agree to work for the MCO at a cost similar to its other providers.
• You have a right to change to a different care team, up to two times per calendar year, if the MCO has a different care team to offer you. You do not have to give a reason. The MCO does not have to give you the particular care team you prefer.
• You may choose to self-direct all or some of your services. (See next section.)

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What is Self-Directed Supports?

Self-directed supports (SDS) is an option the ADRC tells you about and you discuss with the MCO when you became a member. It is an additional choice available to you if you want to be more involved in the direction of your own services.

SDS gives you considerable choice over how support services are provided and by whom. With SDS, you may have control over your own budget for services, and you may have control over your providers including hiring, training, supervising and firing your own direct care workers.

Though frequently used for in-home care, SDS can also be used outside of the home for services such as transportation and personal care at your work place. You can choose to self-direct some or all of your services. For example, you could choose to self-direct services that help you stay in your home or help you find and keep a job, and use your care team to manage services aimed at other outcomes in your plan.

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What happens if I choose SDS?

If you choose the SDS option, the MCO will make resources (including a budget) available to you. The budget is based on what the MCO would otherwise spend on your services. You can then use that budget amount to buy any long-term care service or support, in the benefit package that will work to meet your personal outcomes. Your care team will approve your plan for using your SDS budget.

When you choose the SDS option, your care team will meet with you to answer the following important questions:

• What service do you want to self-direct and how much do you want to participate in self-directing that service?
• What will your budget be for self-directed services/supports?
• How much responsibility do you want in managing your own budget - and what type of supports would you like? MCOs have contracted fiscal agents and co-employment agencies that can help you.
• Do you think you will need training or other resources to fully participate in SDS the way you would like to?
• Who do you want to have provide your services and supports?
• Do you have family, friends, or others who you would like to help you with participating in SDS?
• Are there any health and safety issues that should be addressed in your SDS plan? If so, do you have ideas for how to deal with them? For instance, you may want to have a back-up plan if your personal care provider is unavailable.

It is helpful to think about these questions and discuss these with friends or family prior to meeting with your care team. The answers to these questions will be written clearly in your individual service plan. The MCO must give you a copy of your plan.

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Can I get help to participate in SDS?

Choosing SDS does not mean you are left on your own to do everything. There are a variety of supports available to you if you would like, including:

• Fiscal agents are available to help with payroll functions - for example, writing checks and taking out tax deductions.
• Co-employment agencies, which help with payroll and other things as well - for example, writing a job description, recruiting and training workers.
• Your care team can help you with a variety of activities - for example, creating a budget, developing a back-up plan, and finding needed resources.
• Community resources can also be very helpful - for example, family, friends, neighbors, churches, etc.

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What if SDS is not working for me?

You can stop participating in SDS at any time, and your care team will take care of managing your care plan. If you want to make a change, just talk to your care team. You can also work with your care team to find ways to make SDS work better for you.

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Can the MCO limit my participation in SDS?

MCO care teams are responsible for your health and safety, and ensuring that funds are being used responsibly. The MCO may limit your participation in SDS if it finds that:

• You are not staying within your set plan and budget.
• You are using resources in a way that is illegal.
• Your health and safety or another person's health and safety is threatened.
• Someone else is making decisions for you that are not based on what you want.

If the MCO limits your participation in SDS, the MCO must tell you how to file a grievance or ask for a hearing. Also, your care team must work with you to make changes needed for you to participate in SDS again, if you want.

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How can I learn more about SDS?

There are many ways to find out more about SDS, including:

• Talking to your care team,
• Talking to other members who have participated in SDS, and
• Looking at the SDS information on the Family Care website or on the Waisman Center's SDS Resource Library (Exit DHS). The websites provide SDS information and resources for providers, consumers, guardians, families and friends.

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What if you and the MCO cannot agree on a member-centered plan?

You and your care team may not always be able to agree about which service will be most effective or cost-effective. Reasonable people can disagree. You and your care team should use the Resource Allocation Decision method to talk through your preferences and the different options. The MCO must offer to provide the services in the plan, even if you do not fully agree with it. Accepting the services in your plan does not mean you cannot file a grievance or appeal, or ask for a fair hearing. The MCO should keep talking to you about other ways to provide services that you and the MCO might be able to agree on.

Family Care and Partnership provides you with three ways to file a grievance or appeal. See the section, 'What choices do you have if you want to file a grievance or appeal?'

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How will you know about Family Care or Partnership decisions?

If the MCO plans to reduce or stop a service you have been receiving, it must send you a notice of action that explains the decision. The MCO must also send you a notice of action if it denies a service you requested. The notice of action will tell you how to file a grievance or appeal if you disagree with the decision.

If the MCO stops or reduces services that you have been getting already, and you appeal before the day the change will take effect, you can ask to have the services continue until the grievance or fair hearing decision is made. However, you may have to pay back the cost of the continued services if you lose your appeal.

Your eligibility and cost sharing will be reviewed at least once every year by an Income Maintenance or Economic Support worker. If there is a change in eligibility or cost share, you will get a notice. You can also file a grievance or ask for a state fair hearing if you think the change is wrong.

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What choices do you have if you want to file a grievance or appeal?

Family Care and Partnership give you several choices if you have a concern about your service plan. Your family, a friend, or a provider may file an appeal or grievance on your behalf if they have your permission or your guardian's permission. You can:

• File a grievance or appeal with the MCO.
• Ask for a review by the Wisconsin Department of Health Services (DHS), which is the agency that contracts with the MCO for Family Care or Partnership services.
• Ask for a state fair hearing.

You must file the grievance, appeal, request for DHS review or request for fair hearing within 45 days from the date of the action or incident being grieved or appealed. Within that timeframe, you can choose to use any or all of the three ways listed above to file a grievance or appeal. You can use these methods together or at different times.

The appeal and grievance procedures are detailed in the Member Handbook. The MCO, its providers, or DHS are not permitted to treat you differently because you filed an appeal, grievance, or requested a fair hearing.

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How do I file a grievance or appeal with the MCO?

To file a grievance or appeal with your MCO, you can either speak directly with a member of your care team or contact the MCO person identified in your member handbook whose job it is to help you with grievances and appeals.

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How do I request a review by the Department of Health Services?

To request a review by DHS, contact the Family Care and Partnership Grievance hotline either by writing, calling or e-mailing:

DHS Family Care and Partnership Grievances
c/o MetaStar
2909 Landmark Place
Madison, WI 53713
Phone: (888) 203-8338 (HOTLINE)
Fax: (608) 274-8340
E-Mail: dhsfamcare@wisconsin.gov 

You will be notified in writing within five days that your grievance or appeal has been received, and someone will be in touch with you to help you resolve the situation.

You will be asked whether you have already used the MCO's grievance process or requested a fair hearing to try to resolve your issue. Concerns can often be resolved directly with the MCO, before asking the State to review the situation. Using the MCO's grievance process first is not a requirement, but it is encouraged.

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How do I request a fair hearing?

You can ask your MCO to help you file a fair hearing, or you can make a request directly to the Division of Hearings and Appeals. Requests for a fair hearing must be made in writing to the following address and should include: your name, mailing address, a brief description of the problem, which county and MCO took the action or denied the service and your signature.

Family Care and Partnership Request for Fair Hearing
c/o DOA Division of Hearings and Appeals
5005 University Avenue, Suite 201
P.O. Box 7875
Madison, WI 53707-7875
Phone: (608) 266-3096
TTY: (608) 264-9853
Fax: (608) 264-9885
Website: http://dha.state.wi.us (exit DHS)

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Is there anyone at my MCO to help me with a grievance?

Each MCO has someone whose job it is to help members with grievances and appeals. The staff position and phone number of the person at your MCO who can help you are listed in your Family Care Member Handbook or the Partnership Evidence of Coverage and there is also contact information on the Family Care web site (PDF, 39 KB).

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What are some places outside of the MCO where I can get help?

An advocate is someone who helps you make sure your needs and outcomes are being addressed by the MCO. You can ask anyone you want to act as an advocate for you, including family members or friends.

Some other places you may get help in making sure your needs and outcomes are addressed are:

You probably already met with a counselor at the Aging and Disability Resource Center (ADRC) who helped you to learn about Family Care and/or Partnership. The ADRC counselor also determined whether you are eligible for the program based on your financial situation and the amount of care and support you need. After you enroll in the MCO, the ADRC can continue to give you information about opportunities and services in the community, as well as public benefits like Medicare, Homestead Tax Credit, or opportunities to earn income without losing Medicaid.

If you are thinking of disenrolling from Family Care or Partnership, you will need to talk to the ADRC about other options for getting long-term care services, and to process the disenrollment. ADRCs also provide information and assistance to:

• People who are in nursing homes or other institutions and want to live in the community;
• People experiencing abuse or neglect; and
• People who live in the community but are at risk of going into an institution because they cannot get the services and supports they need to remain in the community.

The ADRC can also tell you about other people or organizations that can help you or be an advocate for you. Some of these are listed below. Your Family Care Member Handbook or Partnership Evidence of Coverage will also include a list of advocates. Ask your ADRC for more information about them.

Disability Benefit Specialists are on staff at each of the ADRCs (except at Milwaukee) and work with people ages 18-59 with physical and/or developmental disabilities. A Disability Benefit Specialist provides assistance on application and eligibility issues for a broad range of public and private benefits and programs. A Disability Benefit Specialist is also available to provide information on the MCO internal grievance procedure and/or state-level grievance options.

Elderly Benefit Specialists can help MCO members age 60 and over by providing information on the MCO's internal grievance procedure and/or state-level grievance options. You can contact the ADRC to get in touch with an Elderly Benefit Specialist.

Ombudsman Programs

Regional Ombudsmen are available to respond to your concerns in a timely fashion. Both Ombudsmen programs will typically use informal negotiations to resolve your issues without a hearing.

• Wisconsin Board on Aging and Long Term Care (Exit DHS) Ombudsman from this agency provide advocacy to Family Care and Partnership members age 60 and older.
  
  Board on Aging and Long Term Care
  1402 Pankratz Street, Suite 111
  Madison, WI 53704-4001
  Toll-free: 800-815-0015
  Fax: 608-246-7001
  
  
• Disability Rights Wisconsin (DRW) (Exit DHS) Ombudsman from this agency’s three offices provide advocacy to Family Care and Partnership members under age 60.
  
  131 W. Wilson St., Suite 700
  Madison, WI 53703
  608-267-0214
  TTY: 888-758-6049
  Fax: 608-267-0368
  Madison Toll-free: 800-928-8778
  Milwaukee Toll-free: 800-708-3034
  Rice Lake Toll-free: 877-338-3724

Independent Living Centers (ILCs) are consumer-directed, non-profit organizations that provide an array of services, including peer support, information and referral, independent living skills training, advocacy, community education, personal care and service coordination.

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Glossary of Terms

ADRC (Aging and Disability Resource Center) - The first place to go with your aging and disability questions. ADRCs are service centers that provide a place for the public to get accurate, unbiased information on all aspects of life related to aging or living with a disability.

Appeal - A request for review of an action.

Department of Health Services (DHS) - State agency that contracts with the MCO for Family Care and Partnership services.

Comprehensive Assessment (assessment) - is the process for the care team to have a clear understanding of the member and the services and items necessary to support the member's individual outcomes, needs and preferences. The comprehensive assessment shall be completed within 90 calendar days from enrollment.

Cost-share (Spend down) - Sometimes members are required to pay a share of the cost of the services they receive.

Fair Hearing - A hearing held by an Administrative Law Judge who works for the Division of Hearings and Appeals. This Division is independent of both the MCO and DHS.

Grievance - An expression of dissatisfaction about any matter other than an action.

Family Care - A comprehensive and flexible long-term care service system, Family Care strives to foster people's independence and quality of life, while recognizing the need for interdependence and support.

Family Care Partnership (Partnership) - Formerly known as Wisconsin Partnership Program, integrates health and long-term support services.

Interdisciplinary Team (Care Team) - Referred to as your 'care team' in this booklet. The interdisciplinary team, which includes the member, defines the member's personal outcomes and creates the member-centered plan.

MCO (Managed Care Organization) - Operates Family Care and Partnership long-term care programs.

Member - A person who is enrolled in Family Care or Partnership.

Member-Centered Plan or MCP - An ongoing plan that documents a process by which the member and the care team further identify, define and prioritize the member's personal and quality of life outcomes. The MCP includes how informal and community resources, and services and supports available through the MCO benefit will be used to achieve the member's personal outcomes. The MCP shall be completed and signed by the member within 90 calendar days from enrollment.

Notice of Action - A written notice from the MCO explaining specific change in service and the reason(s) supporting the change in service.

Ombudsman - One that investigates reported complaints, reports findings, and helps to achieve equitable settlements.

Personal Outcomes - Represent what is important to the member, or are things the member wishes were different in his or her life.

RAD (Resource Allocation Decision) - A step-by-step tool you and your care team will use to help determine the most effective and cost-effective way to achieve your outcomes.

SDS (Self-Directed Supports) - An option in Family Care and Partnership that gives you considerable choice over how support services are provided and by whom.

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Goals of the Family Care initiative:

CHOICE - Give people better choices about the services and supports available to meet their needs.

ACCESS - Improve access to services.

QUALITY - Improve quality through a focus on health and social outcomes.

COST-EFFECTIVE - Create a cost-effective long-term care system for the future.

Wisconsin Department of Health Services
Division of Long Term Care
Office of Family Care Expansion
P.O. Box 7851
Madison, Wisconsin 53707-7851
http://www.dhs.wisconsin.gov/LTCare  

P23189 (January 2010)

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