What is Home Care?

Private Pay is when you pay for home health services out of pocket.  If you choose to Privately Pay for your services, PHCS does offer competitive rates.

If you have Medicare, you can use your home health benefits if you meet ALL five of the following conditions:

1. You must be under the care of a doctor, and you must be getting home health care services under a plan of care established and reviewed regularly (usually every 60 days) by a doctor.  Only an MD or DO can order home health care services.  Practitioners like a Physician’s Assistant or Nurse Practitioner, CANNOT order home health services.
2. You must need, and a doctor must certify that you need, one or more of the following skilled home health care services:
   1. Intermittent skilled nursing care
   2. Physical therapy
   3. Speech-language pathology services
   4. Continued occupational therapy

See our SERVICES page for more detail on these services.

3. The home health agency caring for you must be approved by Medicare (Medicare-certified). PHCS is Medicare-certified.
4. You must be homebound, and a doctor must certify that you’re homebound.  Your doctor must create and sign and date a “Physician’s Medicare Certifying Statement.”  To be homebound means the following:
   1. Leaving your home isn’t recommended because of your condition.
   2. Your condition keeps you from leaving home without help (such as using a wheelchair, walker, cane, crutches; special transportation, or getting help from another person).
   3. Leaving home takes a considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.
5. As part of your certification of eligibility for Home Health Care under the Medicare benefit, you need to have a “face-to-face” encounter with your doctor or a Physician’s Assistant or Nurse Practitioner that works with your doctor.  During this encounter your doctor or the practitioner needs to document that you would benefit from home health care services, which services specifically, and the reasons why.

The Home Health Agency must obtain the face-to-face encounter and the Physician’s Medicare Certifying Statement before we can provide home health care services. If the home health agency does not get this information, Medicare will deny any payment. So, it is very important for physicians to understand what is needed.  Unfortunately, many doctors do not know or understand what is needed.

Medicare Eligibility is also based on the amount of services you need

If you meet the conditions above, Medicare pays for your covered home health services for as long as you’re eligible and your doctor certifies you need them. If you need more than part-time or “intermittent” skilled nursing care, you aren’t eligible for the home health benefit.

To decide whether you’re eligible for home health care, Medicare defines part-time or “intermittent” as skilled nursing care that’s needed or given on fewer than 7 days each week or less than 8 hours each day over a period of 21 days (or less).

Medicare does Not pay for:

1. 24-hour-a-day care at home.
2. Meals delivered to your home.
3. Homemaker services like shopping, cleaning, and laundry when this is the only care you need, and when these services aren’t related to your plan of care.
4. Personal Care Services given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.  This is a link to more information about Medicare and Home Health Care: Medicare Home Health Services.

Wisconsin Medicaid, also known as Medical Assistance or Title XIX (Title 19), is a government health care program paid for by the state of Wisconsin and the federal government. To be eligible for Medicaid:

• You must be 65 or over, or disabled, or blind; and
• You must have family income at or below the monthly program limit; and
• You must be a US citizen or legal immigrant.

There are a few different Medicaid plans.  The type of plan or program you may be eligible for depends on your income, assets, and type of care you need.

If you are eligible, Medicaid may pay for long-term home health care. You must be under a doctor's plan of care, have medical needs that can be met in your own home, and receive services from a home health care agency certified by Medicaid.  PHCS is Medicaid certified.

Wisconsin Medicaid does pay for Personal Care Services given by a home health aide like bathing, dressing, and using the bathroom, if you qualify for these services.

Some of the different Medicaid programs that might offer home health care services include:

Community Waivers help elderly, blind or disabled people live in their own homes or in the community, rather than a state institution or a nursing home.

Medicaid Deductible plan can help if you have high medical bills and your income is over the Medicaid program income limits.

Medicaid Purchase Plan provides health care for people with disabilities who work.

Medicare Savings Programs (also called Medicare Premium Assistance) can help some people pay their Medicare Part A and B premiums, coinsurance and deductibles.

To see what programs you may be able to enroll in, visit ACCESS.wi.gov and click on "Am I Eligible?" or go directly to "Apply for Benefits."

FAMILY CARE– The Family Care Partnership Program is an integrated health and long term care program for frail elderly and people with disabilities. The Partnership Program consists of several managed care organizations located in different geographical regions of Wisconsin.

The goals of Family Care are to:

• Improve quality of health care and service delivery while containing costs;
• Reduce fragmentation and inefficiency in the existing health care delivery system; and
• Increase the ability of people to live in the community and participate in decisions regarding their own health care.

The Managed Care Organizations within Southeastern Wisconsin are:

• Community Care, Inc.
• Care Wisconsin
• Inclusa
• My Choice Family Care 

If you are a Family Care member, you may qualify for home health care.  If you would like PHCS to provide your home health care, you must let the Managed Care Organization that coordinates your services know that you would like PHCS to provide your services.  One of Family Care’s goals is to allow you to make decisions regarding your own health care.  You have a right to choose your home health provider.

Most traditional (commercial) Health Insurance Plans will pay for some home health care.  With traditional Health Insurance, each plan is different as to the amount of home health coverage you are allowed per coverage year, and as to what the eligibility requirements are for home health care services.

All Health Insurance Plans require Prior Notification for Home Health Care.  This means that before you can receive home health services, PHCS must contact your Health Insurance Company, and request authorization to provide services to you.  PHCS cannot start services until we receive authorization from your Insurance Company.

Most Health Insurance plans follow eligibility rules similar to Medicare’s eligibility rules.

Some commercial or traditional insurance providers include:

• UnitedHealth Care
• Humana
• Aetna

Traditional Health Insurance Plans do Not pay for:

1. 24-hour-a-day care at home.
2. Meals delivered to your home.
3. Homemaker services like shopping, cleaning, and laundry when this is the only care you need, and when these services aren’t related to your plan of care.
4. Personal Care Services given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.

BadgerCare Plus is a health care coverage program for low-income Wisconsin residents.  The only way to know if you are able to enroll in the BadgerCare Plus Program is to apply. You can apply any- time for BadgerCare Plus and other assistance programs online at ACCESS.wi.gov. Because BadgerCare Plus does not have an open enrollment period, you can apply for BadgerCare Plus at any time.

Most families participating in the Wisconsin BadgerCare Plus program receive their health care through HMOs (health maintenance organizations.) The health care services offered by these plans are very similar to what Wisconsin Medicaid or Title 19 offer, including Personal Care Services.  Some people who are eligible for both Medicare and Medicaid (Dual Eligible) can receive both Medicare and Medicaid benefits from their HMO. 

Some very good BadgerCare Plus HMOs in the Metro Milwaukee area are:

• UnitedHealth Care Community Plan
• Trilogy (local Milwaukee Insurance Company)

PHCS is contracted to provide services to most BadgerCare Plus HMO Plans in Southeastern Wisconsin.

Long-Term Care Insurance is a type of insurance developed specifically to cover the costs of nursing homes, assisted living, home health care and other long-term care services. These services are usually not covered by traditional health insurance or Medicare.

Long-Term Care Insurance does not pay for Skilled Services because traditional health insurance or Medicare usually pays for these services.  Long-Term Care Insurance does pay for personal care services.  The policy holder typically has to privately pay for a set number or home health visits before Long-Term Care Insurance will start paying.  The number of visit you will have to privately pay for is based on your policy.