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Espaņol
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Russian translation (PDF, 305 KB)
Being a Full Partner
May 2008
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.
Who should read this
booklet?
This booklet is written for Family Care and Family Care Partnership
(Partnership) members and anyone deciding whether to enroll in one of
these managed long-term care programs. Managed Care Organizations (MCOs)
operate these long-term care programs. MCOs 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.
The word "member" means a person who is enrolled in an MCO's
Family Care or Partnership Program. The word "you" is used to
refer to a Family Care or Partnership member or potential member, but 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.
Under 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 enrollment decision.
Each MCO has a member handbook (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 (network listing) to each member.
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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 service plan.
- 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 increased
consumer choice, improved access to services, and improved quality through
a focus on health and personal outcomes.
Family Care provides a full range of long-term care services.
Partnership, formerly known as Wisconsin Partnership Program, integrates
health and long-term support services.
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 must 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 decide how I spend my day.
- I have relationships with family and friends I care about.
- I do things that are important to me.
- 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 ombuds 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 an assigned MCO nurse practitioner and your primary care doctor.
Usually the nurse practitioner communicates with your doctor, who may or
may not attend your care plan meetings.
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 service 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 of identifying the real-life personal outcomes that matter to you
and your unique strengths and needs for support.
Being a full partner in the assessment means:
- A face-to-face meeting must be held with you to discuss your needs
and preferences, and you must be told the purpose of the meeting.
- If you want other people involved, your care team must support and
encourage those people to be involved.
- MCO staff must ask you what you want your life to be like, and what
you see as your most important support needs.
- Your answers must be used in deciding what personal outcomes your
service plan will try to achieve for you. (See the next section.)
- Even if you are already receiving some help, MCO staff must 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 individual service plan?
The MCO must develop an individual service plan for you that will help
you move toward the personal outcomes that you and your care team
identified in the assessment. The plan must be clear about:
- What services and supports you will receive to achieve your personal
outcomes,
- Who is going to provide you with each service or support, and
- When each service or support will be provided.
This includes things you are going to do yourself or with help from
family or friends. The MCO must give you a copy of your plan.
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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 service plan should be both reasonable and effective.
This means that you do not have to settle for a service 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 service 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 MCO members achieve their personal outcomes.
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How do Family Care and Partnership help you control of your own services?
Family Care and Partnership strive to respect the choices of their
members. For example:
- Having the living arrangement, daily routine and support services of
your choice are examples of the general outcomes 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, 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 explained to you at the ADRC
and when you enter the MCO. 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 based on what the MCO would have spent on your
services. You can then use that budget amount to buy any service or
support that will work to meet your personal outcomes.
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, and Independent Living Centers.
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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
- Going to the Self-Directed Supports
(SDS) Resource eLibrary
(exit DHFS). This website provides 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 service 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 within 14 days of getting the notice, 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 and Family
Services (DHFS), 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 DHFS 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 Family Care
Member Handbook and in the Partnership Evidence of Coverage. Filing an
appeal, grievance, or requesting a fair hearing will not negatively affect
the way the MCO, its providers, or DHFS treats you.
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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 and Family Services?
To request a review by DHFS, contact the Family Care and Partnership
Grievance hotline either by writing, calling or e-mailing:
DHFS 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: famcare@dhfs.state.wi.us
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
DHFS)
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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.
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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 being addressed are:
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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 and Family Services (DHFS) - State agency
that contracts with the MCO for Family Care and Partnership services.
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 DHFS.
Grievance - An expression of dissatisfaction about any matter
other than an action.
Individual Service Plan (ISP) - Upon enrollment, the care team
shall develop and implement an initial ISP, based on information received
from the ADRC and on the MCO's initial assessment of the member's needs.
The initial ISP shall be developed by the MCO in conjunction with the
member. The MCO shall contact the member within three calendar days of
enrollment to develop an initial ISP and the initial ISP shall be signed
by the member within ten (10) days of enrollment.
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.
MCO (Managed Care Organization) - Operates Family Care and
Partnership long-term care programs.
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 individual
service plan.
Member - A person who is enrolled in Family Care or Partnership.
Notice of Action - A written notice from the MCO explaining
specific change in service and the reason(s) supporting the change in
service.
Ombuds - 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.
Family Care and/or Partnership long-term care
programs are currently available in a growing number of Wisconsin
counties.
As a comprehensive and flexible long-term care service system,
Family Care and Partnership strive to foster consumers'
independence and quality of life, while recognizing the need for
interdependence and support.
This booklet is also available in Espaņol, Hmong, Russian,
Braille and large-print. |
Wisconsin Department of Health and Family Services
Division of Long Term Care
Office of Family Care Expansion
P.O. Box 7851
Madison, Wisconsin 53707-7851
http://dhfs.wisconsin.gov/LTCare
PDE-3189 (May 2008)
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Booklet version
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Large
print (PDF, 95 KB; 45 pages)
Hmong
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Espaņol
translation (PDF, 116 KB)
Russian translation (PDF, 305 KB)
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Last Revised: August 05, 2008 |
