Family Care, Family Care Partnership, and PACE: Standard Definitions for Managed Care Terms

Wisconsin Department of Health Services (DHS) requires managed care organizations (MCOs) to use the following definitions in member materials.

MCO terms and definitions

See common terms and definitions below.

• Appeal—A request for your MCO to look at a decision that affects your services. You have the right to file an appeal if your care team stops, denies, or reduces a service. 
• Copayment—A fixed amount of money you pay for a covered health care service. For example, you may have a $5 copay for a visit to the doctor.
• Durable medical equipment—An item or device meant for you to use each day. You may need it to help with a health issue or disability. Examples:
  • Oxygen equipment
  • Wheelchairs
  • Walkers
• Emergency medical condition—An illness, injury, symptom, or condition that is very serious. Most people would seek care right away to avoid harm.
• Emergency medical transportation—An ambulance that you travel in for an emergency medical condition.
• Emergency room care—Health care services you get in the emergency department of a hospital.
• Emergency services—Care or treatment for an emergency medical condition.
• Excluded services—Services that your MCO or Medicaid does not cover.
• Habilitation services—Health or long-term care services that support daily living. They may help you keep, learn, or improve certain skills or functions.
• Health insurance—A contract that says a health insurer must pay some or all of your health care costs.
• Home health services (or home health care)—Health and long-term care services you get at home, work, or in the community. Examples:
  • Home health aide services
  • Medical supplies and equipment o Nursing care
• Hospice care services—Care that comforts and supports someone in the last stages of a fatal illness. Includes support for family and friends.
• Hospitalization—Care in a hospital. Requires you to stay at the hospital (inpatient). Often means staying overnight.
• Hospital outpatient care—Care in a hospital or outside clinic. Often doesn’t make you check in or stay overnight.
• Medically necessary—Approved health and long-term care services or supplies. These are needed to diagnose or treat:
  • A condition
  • A disease
  • An illness
  • An injury
  • Symptoms
• Network—Who your MCO contracts with to provide health and long-term care services. Includes facilities, providers, and suppliers.
• Network provider (or participating provider or provider)—A person or group who has a contract with your MCO. They can give you services.
• Non-network provider (or non-participating provider)—A person or group who doesn’t have a contract with your MCO to give you services. To use a non-network provider, members first must contact their MCO.
• Physician services—Health care services that a licensed medical doctor gives or directs. You may receive these services:
  • In a doctor’s office.
  • At the hospital.
  • At a nursing home.
  • In your home.
• Plan—Coverage that provides or pays the cost of your medical care.
• Prior authorization (or pre-authorization)—Written approval for a service or prescription. You may need this from your MCO or DHS before you get a service or fill a prescription.
• Premium—The amount you pay each month for health or prescription drug coverage. You may pay to either:
  • A health care plan.
  • An insurance company.
  • Medicare.
• Prescription drug coverage—Part of your health insurance plan. Payment of some or all costs for:
  • Medical supplies.
  • Over-the-counter medicines.
  • Prescription drugs.
• Prescription drugs—Drugs and medicines that, by law, you must have a prescription to get. This means a medical provider says you need the drugs or medicine.
• Primary care physician—The medical doctor who gives or directs your health care services.
• Primary care provider—The person who gives, directs, or helps you get health care services. Includes:
  • Doctors or nurse practitioners
  • Physician assistants
  • Other licensed providers
• Rehabilitation services—Services you have after an illness, injury, or disability. They help you keep, get back, or improve functions for daily life.
• Skilled nursing (or skilled nursing care)—Certain services your doctor says you need. They are provided by either:
  • An advanced practice nurse.
  • A registered nurse.
  • A licensed practical nurse supervised by a registered nurse.
• Specialist—A doctor who is an expert in an area of medicine.
• Urgent care (or urgent service needs)—Care for an illness, injury, or condition that needs medical help right away. It does not require emergency room care.

Questions? Contact the Bureau of Programs and Policy at dhsdmsltc@dhs.wisconsin.gov.