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What is Home Care?

“Home Care” is a simple phrase that encompasses a wide range of health and social services.  These services are delivered at home to recovering, disabled, chronically or terminally ill persons in need of medical, nursing, social, or therapeutic treatment and/or assistance with the essential activities of daily living.Generally, home care is appropriate whenever a person prefers to stay at home but needs ongoing care that cannot easily or effectively be provided solely by family and friends.  More and more older people, electing to live independent, non-institutionalized lives, are receiving home care services as their physical capabilities diminish.  Younger adults who are disabled or recuperating from acute illness are choosing home care whenever possible.  Adults diagnosed with terminal illness also are being cared for at home, receiving compassionate care and maintaining dignity at the end of life.  As hospital stays decrease, increasing numbers of patients need highly skilled services when they return home.  Other patients are able to avoid institutionalization altogether, receiving safe and effective care in the comfort of their own homes.

Who is Eligible for Home Health Care? 

  • Do you need help in your home so that you can maintain your independence in the community?
  • Would you or your loved one prefer to be cared for at home instead of an institution?
  • Has your medication recently changed, or do you need help keeping track of your medications?
  • Do you need skilled nursing?
  • Has your medical condition changed recently?
  • Are you a caregiver that is spending a substantial amount of time caring for a family member or friend? Would you like to get compensated for providing cares?

If you can answer “yes” to any of these questions, you may be eligible for home care.  Please contact PHCS at 414-541-6010 or REQUEST SERVICES

Who Pays for Home Care?

PRIVATE PAY

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.

MEDICARE

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

  1. You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
  2. You must need, and a doctor must certify that you need, one or more of the following:
    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.

  1. The home health agency caring for you must be approved by Medicare (Medicare-certified). PHCS is Medicare-certified.
  2. You must be homebound, and a doctor must certify that you’re homebound. 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 or walker, needing 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.

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: http://www.medicare.gov/pubs/pdf/10969.pdf

WI MEDICAID

Wisconsin Medicaid, also known as Medical Assistance or Title XIX, 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 in a family with dependent children; and
  • You must have low income and few assets; or
  • You must be paying so much money for health care that you have very little income left.

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.

FAMILY CARE

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.
  • ContinuUs
  • iCare
  • Milwaukee County Department of 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.

TRADITIONAL HEALTH INSURANCE

Most traditional 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 rules.  These typically include:

  1. You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
  2. You must need, and a doctor must certify that you need, one or more of the following:
    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.

  1. The home health agency caring for you must be in network with the insurance company (some insurance plans will allow you to use out-of-network providers, but you will usually have to pay more out-of-pocket for services). PHCS is in network with most insurance companies that service Southeastern Wisconsin.

If you meet the conditions above, most Health Insurance Plans will pay for your covered home health services for as long as you’re eligible, your doctor certifies you need them, and you don’t exhaust your coverage year maximum for services. If you need more than part-time or “intermittent” skilled nursing care, most health insurance plans will not cover home health services.

To decide whether you’re eligible for home health care, most Health Insurance Plans define 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).

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.

MANAGED CARE HEALTH PLANS

Managed Care Health Plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules.  They will pay for long-term home health care including personal care services, if you qualify for these services.  Some plans in Southeastern Wisconsin include: Children’s Community Health Plan, Inc., Community Care Health Plan, Inc., Compcare Health Services Insurance Corporation, Humana Wisconsin Health Organization Insurance Corp., Independent Care Health Plan (Icare), Managed Health Services Insurance Corp., Molina Healthcare of Wisconsin, Inc., and UnitedHealthcare of Wisconsin, Inc. (Community Plan).

PHCS is contracted to provide services to most Managed Care Health Plans in Southeastern Wisconsin.

LONG-TERM CARE INSURANCE

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.