Family Care and Family Care Partnership: Being a Full Partner

Family Care and Family Care Partnership (Partnership) are programs for older adults and people with disabilities. The programs make sure people get the long-term care services they need to live safely at home or in their community.

Members have more control over their lives and are more involved with their communities. Family Care and Partnership give members choices in where they get services and from whom.

Who is in charge of Family Care and Partnership?

Both programs get funding from state and federal tax dollars. Wisconsin Department of Health Services (DHS) works with managed care organizations (MCOs) to run Family Care and Partnership. MCOs coordinate health and long-term care services for members:

• Family Care covers long-term care services.
• Partnership covers long-term care services and health care.

Learn more about key differences between Family Care and Partnership.

DHS gives MCOs funding each month for each member they serve. MCOs use the funds to cover services for members. Some members must pay a share of the cost for services they get. This is called cost share. If you have a cost share, your ADRC will let you know before you decide to enroll or not.

Each MCO has a Member Handbook. It gives more details about MCO services and member rights. MCOs must give members a Member Handbook. They also must share how to get a list of the providers they often use (called a provider network list). That way, all members know about all services and providers. You and your care team confirm which services are best and fit with your care plan.

What does it mean to be a “full partner”?

We know that you’re the expert on your life. That means you should have a say in what you need for your health and long-term care services. As part of your care team, you help develop your care plan. In other words, you’re a “full partner” when it comes to your care.

As a full partner, you have the right to:

• Be part of decisions that affect your care.
• Choose to involve family or others.
• Tell us what your biggest support needs are and what you want your life to be like.
• Get help from your MCOs to make choices about your services and supports.
• Know service and support options and how much they cost.
• Suggest other services or supports that you think would meet your needs.

As a full partner, you have some responsibilities. You must:

• Meet with your care team face-to-face. You’ll discuss your needs, outcomes, and preferences.
• Figure out the support your family and friends offer now. See what they can continue to offer.
• Choose from the cost-effective options that can meet your needs.

When you enroll in Family Care or Partnership, you choose your MCO. Then, you get a group of people called your care team. They help you figure out what type of support you need. They also help arrange your health and long-term care services.

Who is part of my care team and what do they do?

Your care team includes:

• You.
• A care manager or social service coordinator.
• A registered nurse.
• A nurse practitioner (Partnership only)
• Anyone you want involved. This could be a family member, friend, or person who works on your behalf.
• Other professionals, depending on your needs. For example, this could be an occupational therapist, physical therapist, or mental health specialist.

Your care team works with you to:

• Define your health needs and long-term care outcomes.
• Create a member-centered plan. It outlines the services and other help you need to support your outcomes.
• Ensure your services meet your needs and are cost-effective.
• See that you get the services in your plan.
• Confirm that the plan keeps working for you.

You should be part of the entire process. You can get extra help to take part in the process. This includes an interpreter or person to read to you.

If someone makes legal choices on your behalf, they will be involved with you. They’ll make sure your team hears and respects your voice.

How does my care team know what’s important to me?

You and your care team will do a comprehensive assessment. This goes over your needs, strengths, and preferences. As part of this process, you tell your care team:

• The kind of life you want to live.
• The kind of support you need to live the life you want.
• What you value most.

During the assessment, you define your personal experience outcomes. These are goals you have for your own life. They include:

• Choice
  • Where and with whom to live
  • Supports and services you need
  • Daily routines
• Health and safety
• Independence
  • Community involvement
  • A job or hobby that has meaning
  • Privacy
  • Respect and fairness
  • Stability
  • Time with family and friends

Only you know and can share what’s most important to you. You define what these outcomes mean for you. For example, you might want:

• To be healthy enough to enjoy visits with your grandkids.
• To have a paid job.
• To be able to live in your own apartment.

Your care team will work with you to help you achieve these outcomes. This doesn’t mean Family Care and Partnership can get you all you want from life. Your MCO may not buy all services that help you reach your goals. What you do for you, or what family and friends do for you, are still important to your care and goals.

How does my MCO/care team decide what services and supports I need?

As part of the assessment process, you and your care team define your long-term care outcomes. This helps you and your team know what services and supports will meet your needs. Long-term care outcomes might include:

• Find and get health care.
• Have daily needs met.
• Have a job.
• Get what you need to stay as safe, healthy, and as independent as you can.

Long-term care can help you achieve personal experience outcomes. For example, help with getting dressed or bathing may help you feel well enough to go to work.

Along with your needs, MCOs also must think about how cost-effective a service is. Cost-effective means that a service both:

• Supports a defined long-term care outcome.
• Supports the outcome at a reasonable cost and effort.

If two providers offer what you need, the MCO will choose the one that costs less.

Most MCOs use the Resource Allocation Decision (RAD) process to decide which services to use. This step-by-step tool helps define the best and most cost-effective way to support your long-term care outcomes.

How will Family Care and Partnership involve my family and friends?

Both programs want people who are important to you to be involved in your care. You can choose to include anyone on your care team. They can come with you when you meet with your care manager and/or nurse.

Family Care and Partnership don’t replace the help you get from your current support system. This might include:

• Family and friends.
• Church members.
• Community help at libraries, clubs, or senior centers.
• Neighbors.
• Volunteers.

Services from Family Care and Partnership should build on help you get now. They should not replace your current support system. Rather, they should strengthen it. MCOs pay for services that your own support system cannot give you.

An example is respite. If the people who care for you need a break, your MCO can provide respite services. This relieves caregivers, so they can take care of their own needs and health.

If you don’t have any natural supports or community supports, your care team can help you build a support system.

You work with your care team to create a member-centered plan. It details services that help you achieve the outcomes you define in the assessment process.

What’s in my member-centered plan?

You and your care team create a member-centered plan. It includes:

• Your physical health needs.
• Your ability to do certain tasks, such as eating and dressing.
• Your strengths and preferences.
• The services you’ll get to support your outcomes.
• Who will provide each service or support.
• How often you’ll meet with your care team.
• When you and your care team will look at and update your member-centered plan.
• What you’ll do yourself or with help from family and friends.

Your care team will ask you to sign the completed plan. It shows that you helped develop the plan. Your MCO will give you copy. If you aren’t happy with the plan, you can file a grievance or appeal with your MCO.

Over time, you’ll keep meeting with your care team. They’ll see how you are doing. They’ll check if your services and supports are helping you. Your plan can change as your needs change. Maybe you no longer need a certain service because your physical health improves. Family Care and Partnership services are meant to be flexible. If something changes in your life, contact your care team.

How do I balance my outcomes with service costs?

Your MCO is there to help you achieve your long-term care outcomes. They also must think about costs when they decide on a service. Most MCOs use the RAD process to balance outcomes with costs.

The RAD process is a set of questions you and your care team talk through. It helps you explore what you need and the options that can support you. This includes finding ways your family, friends, or others can assist. The process also helps talk through how much you’d like to direct your care and services.

As a member, you have the right to know about all your options and how much they cost. You should talk to your care team, so you can decide together.

What if I can’t agree with my care team on my member-centered plan?

You may not always agree with your care team. That’s okay. You should use the RAD process to talk through any issues and options.

If you still do not agree with the services in your care plan, you have the right to file an appeal. See the grievances, decisions, and appeals section.

How can Family Care and Partnership help me control my own services?

Family Care and Partnership work to respect the choices of all members. This list includes some of the choices you have:

• Care team—You can change to a new care team, up to two times per year. This is only if your MCO has a new care team to offer. The MCO isn’t required to give you the care team you prefer.
• Family providers—If you ask, MCOs can buy hands-on care or services from your family when care involves coming into your home often. The family member must meet MCO requirements. They also must agree to work at a cost that’s close to the cost of other providers.
• Living arrangements, daily routine, and support services—You can define what you value most for these outcomes. You work with your care team to find the best ways to support these.
• Providers—If you ask, your MCO must consider using a provider it doesn’t often use. This is if the provider would better meet your needs.
• Self-directed supports—You can choose to self-direct one or more services. Learn more in the self-directed supports (SDS) section.

SDS is an option for members who want to manage some of their own services. Often, members use SDS for in-home care. It also can be used outside of the home for services, such as transportation and care at work. You can choose to self-direct one or more of your services.

Your ADRC should tell you about SDS options before you decide to enroll in Family Care or Partnership. After you enroll, you learn more about SDS when you meet your care team.

Why would I choose SDS?

SDS gives members more choice and control over:

• Who provides your services. For example, it could be a family member, friend, or agency.
• What services you need.
• How you want your caregivers to do certain tasks.
• When you get services.

With SDS, you also may have control over your own budget for services. You may control hiring, training, supervising, and firing direct care workers.

What happens if I choose SDS?

Your MCO helps you find and pay for services you need. If you choose SDS, you work with your care team to talk through your options. You also set a budget. You can expect these questions from your care team:

• What service do you want to self-direct? How much of a role do you want in self-directing that service?
• What will your budget be for self-directed services?
• How much do you want to control your own budget? What type of supports would you like?
• Do you need training or other resources to use SDS how you’d like?
• Who do you want to provide your services and supports?
• Do you have anyone who would like to help you with SDS? Includes family, friends, or others.
• Are there any health and safety issues to add to your SDS plan? If yes, do you have any thoughts on how to deal with them? For instance, what will you do if your personal care provider is busy or unable to help?

It’s helpful to think about these questions before your meeting with your care team. You also should talk about them with family and friends. Your answers to these questions will go in your member-centered plan.

Once your care team approves your approach to SDS, you can use your budget to buy services that:

• Are eligible for self-direction.
• Are in your member-centered plan.
• Support your needs and outcomes.

Can I get help with using SDS?

Yes. Choosing SDS doesn’t mean you are left on your own with no support. There are still supports you can use, such as:

• Co-employment agencies—They can help with payroll and things like writing a job description and recruiting and training workers.
• Fiscal agents—They can help with payroll functions. Includes writing checks and taking out tax deductions.
• Your care team—They can help you create a budget, define a back-up plan, and find resources.

What if SDS isn’t working for me?

You can stop using SDS at any time. Just talk to your care team. They can help find ways to make SDS work better for you. They also can take over managing your care plan.

Can my MCO limit how much I use SDS?

Your MCO is in charge of your health and safety. They must make sure you’re using funds in the best way you can. Your MCO may limit how you use SDS if:

• You do not stay in your set plan and budget.
• You use resources in a way that is illegal.
• Your health and safety (or another person’s) are at risk.
• Someone decides for you, and it’s not based on what you want.

If your MCO limits how you use SDS, they must tell you how to file a grievance or appeal.

Where can I learn more about SDS?

To find out more about SDS:

• Talk to your care team.
• Talk to other members who have used SDS.
• Look at the SDS information on the Waisman Center website. It includes resources for members, providers, legal decision-makers, families, and more.

A grievance is when you are not happy with your care team, one of your providers, or the quality of your care or services. For example, you might want to file a grievance if:

• Your personal care worker often arrives late.
• You feel your care team doesn’t listen to you.
• You have trouble getting appointments with a provider.

You can file a grievance with your MCO at any time.

Appeals

As a member of Family Care or Partnership, you have the right to challenge MCO decisions. This is called an appeal.

Your MCO may make a decision that impacts your care. They must give you a written notice of adverse benefit determination if:

• They stop your services.
• They deny you services.
• They reduce your services.
• They refuse to pay for a service.

The notice must tell you when the change will take effect and explain the reason. It also must tell you how to file an appeal with your MCO if you don’t agree.

You may be able to keep getting services during the appeal process. You must file the appeal on or before the day the change will take effect. If you lose your appeal, you might have to pay back the cost of the services you got during this time.

You must file your appeal within 60 days of the mailing date on the notice of adverse benefit determination. This comes from your MCO.

At least once each year, an income maintenance worker reviews your financial eligibility and cost share. If there’s a change, you’ll get a notice. You can ask for a state fair hearing if you think the change is wrong.

Note: The MCO, its providers, and DHS are not allowed to treat you differently because you filed a grievance or appeal.

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

To file an appeal or grievance with your MCO, either:

• Speak with a member of your care team.
• Contact the MCO’s member rights specialist.
• Have your legal decision maker, a family member, friend, or provider file an appeal or grievance on your behalf.

The full grievance and appeal process is in the Member Handbook.

Who can help me with grievances and appeals?

Each MCO has a person assigned to help members with a grievance or appeal. You can find the contact in either:

• Your Member Handbook
• Family Care MCOs Key Contacts (PDF)

You also can ask someone to be an advocate for you. An advocate helps you make sure the MCO addresses your needs and outcomes. You can choose any person, such as a family member or friend.

These groups also can help:

ADRCs

If you are a member of Family Care or Partnership, you already worked with your ADRC. ADRCs serve the public and offer information. They also help with issues that affect older adults, people with disabilities, and their families. ADRCs make it easy to learn about resources near you.

Contact my ADRC.

If you disenroll from Family Care or Partnership, your ADRC can help you find other long-term care options.

ADRCs also help:

• People in nursing homes or institutions who want to live in the community.
• People who experience abuse or neglect.
• People who live in the community who are at risk of going to an institution. They cannot get the services and supports they need to stay where they live now.

Benefit specialists

There are two types of staff who can help you with benefits, based on your age:

• Disability benefits specialists (ages 18–59)—Staff at each ADRC. Work with people who have a disability. Provide help with applying and learning about eligibility for different programs. Can also help with MCO grievance and appeals process.
• Elder benefits specialists (ages 60 and older)—Staff trained to help people having problems with private or government benefits. Also help older MCO members with the grievance and appeals process.

Independent living centers

Independent living centers are non-profit groups. They offer:

• Advocacy.
• Community education.
• Independent living skills training.
• Information and referrals.
• Peer support.
• Personal care.
• Service coordination.

Ombudsman programs

An Ombudsman (om-budz-man) is a person who responds to issues and complaints about Family Care and Partnership. They often use informal meetings to solve your issue. This is different than the formal grievance or appeal process. You can find an Ombudsmen through these groups:

• Disability Rights Wisconsin—Advocate for Family Care and Partnership members aged 18–59.

Disability Rights Wisconsin
1502 West Broadway, Suite 201
Madison, WI 53713 

Toll-free: 800-928-8778 (711 Wisconsin Relay)

• Wisconsin Board on Aging & Long Term Care—Advocate for Family Care and Partnership members aged 60 and older.

Board on Aging & Long Term Care
1402 Pankratz St., Suite 111
Madison, WI 53704

Toll-free: 800-815-0015 (711 Wisconsin Relay)

Find terms and definitions from this web page.

• Adverse benefit determination—A decision from your MCO. Common types include an MCO stopping or reducing your services. An MCO may also deny a request for a new service.
• Aging and disability resource center (ADRC)—The first place to go with aging or disability questions. ADRCs are service centers. They offer information for the public. Learn more about ADRCs.
• Appeal—A request for your MCO to look at a decision that affects you getting services (adverse benefit determination). You have the right to file an appeal if your care team stops, denies, or reduces a service. Learn more about filing an appeal.
• Care team—Your care team. Includes a registered nurse, social worker (or social services coordinator), nurse practitioner (Partnership), and others. You work with your care team to define outcomes and create a member-centered plan.
• Community supports—Services and supports that MCOs don’t approve or pay for. These supports are for the public. Includes libraries, churches, senior centers, and community centers.
• Comprehensive assessment—The process the care team uses to get to know you. Helps find the services and items to support your needs. Includes personal and long-term care outcomes and preferences. You and your care team do the assessment within 30 days after you enroll.
• Cost-effective—A service or support option that helps with a defined long-term care outcome. The effort and cost must be reasonable.
• Cost share—Money you may have to pay each month to get services. The ADRC tells you if you will have a cost share and the monthly amount.
• Fair hearing—A hearing with a judge who works for the Wisconsin Division of Hearings and Appeals. The judge is not part of your MCO or DHS.
• Grievance—When you wish to complain or you’re not pleased with any part of Family Care or Partnership. Does not include adverse benefit determination. Common grievances are concerns about quality care or your care team.
• Family Care—A long-term care service system. Aims to help older adults and people with disabilities achieve independence. Offers support and services where needed. Learn more about Family Care.
• Family Care Partnership (Partnership)—A program that offers both health and long-term care services. Learn more about Partnership.
• Legal decision-maker—A person who, by law, can decide on your behalf. May be either:
  • A guardian of the person or estate (or both) under Wis. Stat. ch. 53.
  • A guardian of the person or estate (or both) under Wis. Stat. ch. 54.
  • A conservator under Wis. Stat. ch. 54.
  • A power of attorney for health care under Wis. Stat. ch. 155.
  • A durable power of attorney under Wis. Stat. ch. 244.
• Long-term care outcome—A setting, condition, or instance that you or your care team says helps you achieve your highest level of independence. Based on your clinical and functional needs.
• Managed care organization (MCO)—An agency that runs the Family Care and/or Partnership program. Learn more about MCOs.
• Member—A person enrolled in Family Care or Partnership.
• Member-centered plan—A defined process for you and your care team. Helps you identify, define, and prioritize your outcomes. Includes how other resources will support your outcomes. You sign this plan within 60 days after you enroll.
• Natural support—Your social support system. Includes family, friends, and neighbors who may be able to help you.
• Ombudsman—A person who looks at reported concerns. Helps resolve issues.
• Personal experience outcomes—A setting, condition, or instance that you define as important to you. Can include what you hope to change about your life.
• Resource allocation decision (RAD) process—A step-by-step tool you use with your care team. Helps find the best and most cost-effective ways to meet long-term care outcomes.
• Self-directed supports (SDS)—An option in Family Care and Partnership. Gives you more choice over who provides supports and services and how.