Family Care: Standard Definitions of Managed Care Terminology

Definitions to be used by managed care organizations in member materials

The Wisconsin Department of Health Services' Family Care, Family Care Partnership, and PACE (Program of All-Inclusive Care for the Elderly) contract requires managed care organizations to use the following standard definitions of managed care terminology in their member materials.

A request for your managed care organization to review a decision that denied, reduced, or suspended a service. For example, if your care team refuses to pay for a service or ends a service, you have the right to file an appeal.
A fixed amount ($5, for example) you pay for a covered health care service.
Durable medical equipment
Equipment for everyday or extended use that you may need because of a medical issue or disability. Durable medical equipment may include oxygen equipment, wheelchairs, or walkers.
Emergency medical condition
An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency medical transportation
Transportation by ambulance for an emergency medical condition.
Emergency room care
Health care services you get in an emergency room.
Emergency services
Evaluation or treatment of an emergency medical condition.
Excluded services
Services your managed care organization or Medicaid do not cover.
Habilitation services
Health and long-term care services that help you keep, learn, or improve skills and functioning for daily living.
Health insurance
A contract that requires a health insurer to pay some or all of your health care costs.
Home health services (also known as home health care)
Health and long-term care services you receive at home, where you work, or in the community. Examples of home health services include nursing, medical supplies and equipment, and home health aide services.
Hospice care services
Services to provide comfort and support for people in the last stages of a terminal illness. These services include providing supportive care to the person’s family and friends.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
Hospital outpatient care
Care in a hospital or outpatient department that usually doesn't require admission to the hospital.
Medically necessary
Health and long-term care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards.
The facilities, providers, and suppliers your managed care organization has contracted with to provide health and long-term care services.
Non-network provider (also known as non-participating provider)
A provider who doesn't have a contract with your managed care organization to provide services to you.
Physician services
Health care services a licensed medical physician (M.D.—medical doctor) provides or coordinates. Services may be provided in a physician’s office, hospital, nursing home, or in your home.
An individual or group health plan that provides or pays the cost of your medical care.
Prior authorization (also known as pre-authorization)
Written approval that may be required from your managed care organization or the State of Wisconsin before you get a service or fill a prescription.
Network provider (also known as participating provider or provider)
A provider who has a contract with your managed care organization to provide services to you.
The amount you pay to Medicare, an insurance company, or a health care plan every month for health or prescription drug coverage.
Prescription drug coverage
The payment of some or all of your costs by a health insurance plan for prescription drugs, over-the-counter medications, and medical supplies.
Prescription drugs
Drugs and medications that, by law, require a prescription.
Primary care physician
The physician (M.D.—medical doctor) who directly provides or coordinates your health care services.
Primary care provider
A primary care physician (M.D.—medical doctor), nurse practitioner, physician assistant, or other licensed provider who provides, coordinates, or helps you access health care services.
Rehabilitation services
Services that help you keep, get back, or improve functioning for daily living due to an illness, injury, or disability.
Skilled nursing (also known as skilled nursing care)
Skilled nursing services your physician orders and that are provided by an advanced practice nurse, registered nurse (RN), or a licensed practical nurse who is supervised by an RN.
A physician who focuses on a specific area of medicine or surgery.
Urgent care or urgent service needs
Care for an illness, injury, or condition that requires medical care right away, but not so severe it requires emergency room care.

Contact information

If you have questions about the standard definitions, contact the Bureau of Adult Programs and Policy.

Last Revised: October 23, 2018