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Being a Full Partner

December 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 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 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 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 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 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 member-centered plan?

The MCO must develop a member-centered 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:

• Your personal outcomes,
• What services and supports you will receive to achieve your personal outcomes,
• Who is going to provide you with each service or support, 
• When each service or support will be provided, and
• Who on the care team is responsible for tracking the supports related to achieving your personal outcomes.

The member-centered plan is an ongoing process, which includes things you are going to do yourself or with help from family or friends. 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.

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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 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
• Looking at the SDS information on the Family Care website. 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 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 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 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 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 DHS 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 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, 24 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 Ombudsman are available to respond to your concerns in a timely fashion. Both Ombudsman programs will typically use informal negotiations to resolve your issues informally.

• Wisconsin Board on Aging and Long Term Care Ombudsman from this agency provide advocacy to Family Care and Partnership members over 60.
  
  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
  http://longtermcare.state.wi.us (exit DHS)
  
  
• Disability Rights Wisconsin (DRW) Ombudsman from this agency's three offices provide advocacy to Family Care and Partnership members under 60.
  
  Headquarters:
  131 W. Wilson St., Suite 700
  Madison, WI 53703
  Phone: 608-267-0214
  Madison Toll-free: 800-928-8778
  Milwaukee Toll-free: 800-708-3034
  Rice Lake Toll-free: 877-338-3724
  
  TTY/TEXTNET: 888-758-6049
  Fax: 608-267-0368
  www.disabilityrightswi.org (exit DHS)
  (includes contact information for all three offices)

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.

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.

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. The ISP is a supplement of the Member-Centered Plan.

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.

Member-Centered Plan or MCP - An ongoing plan that documents a process by which the member and the interdisciplinary team (IDT) 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 ISP is a part of the MCP. The MCP shall be completed within 60 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://dhs.wisconsin.gov/LTCare  

P23189 (December 2008)

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