Insurance & Payment Options

Medicare home health

Medicare may cover eligible home health services under Part A or Part B. Coverage is determined by Medicare rules and the individual’s clinical circumstances; Proxima cannot guarantee eligibility or payment.

Common qualification requirements

• A qualified healthcare provider must evaluate the patient, certify the need for home health, and order the care.
• The patient must need part-time or intermittent skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy.
• The patient generally must be homebound under Medicare’s definition.
• Care must be provided by a Medicare-certified home health agency.

What Medicare generally covers

Covered care may include intermittent skilled nursing, qualifying therapy, medical social services, and limited Home Health Aide care when the patient is also receiving a qualifying skilled service. Medicare does not generally cover round-the-clock home care or personal/custodial care when that is the only service needed.

What to expect

Proxima reviews the referral and orders, verifies available benefits, completes an assessment, and explains the proposed plan of care. Before non-covered services are provided, the patient should receive information about expected financial responsibility and any required Medicare notice.

Medicaid and HealthChoices

Pennsylvania Medicaid, also called Medical Assistance, may cover healthcare and supportive services for eligible residents. Eligibility can depend on income, household size, age, disability, pregnancy, long-term-care needs, and other circumstances.

How to apply

Apply online through COMPASS, by phone through the Consumer Service Center for Health Care Coverage at 1-866-550-4355, by mail, or through a County Assistance Office. Applicants may need identity, residency, citizenship or eligible immigration, household, income, insurance, and resource information.

Physical HealthChoices MCOs

Available plans vary by county. Current Pennsylvania physical-health MCOs across the regions Proxima serves may include AmeriHealth Caritas Pennsylvania, Geisinger Health Plan, Jefferson Health Plans EverWell, Highmark Wholecare, UPMC for You, and, in certain regions, UnitedHealthcare Community Plan. Check the Pennsylvania DHS list for the member’s county and current plan choices.

What to expect

After eligibility and plan enrollment are confirmed, Proxima verifies network participation, covered services, authorization requirements, approved hours or visits, and the plan of care. Coverage is not guaranteed until the applicable payer or MCO confirms it.

Private-pay services

Private pay may be appropriate when insurance does not cover a requested service, when a person does not meet payer eligibility requirements, or when a family wants additional hours or support beyond an authorized benefit.

How Proxima works with private-pay clients

• We begin with a conversation about care needs, location, schedule, safety, and preferred start date.
• We assess whether Proxima can safely staff and provide the requested service.
• Before care begins, we provide written information about services, hourly or visit rates, minimum scheduling requirements, cancellation terms, and billing arrangements.
• We develop a service plan, match appropriate staff, document delivered care, and communicate changes with the client or authorized representative.
• Care may be scheduled during the day, evenings, nights, or weekends based on need and staff availability.

What clients should expect

Clients should receive clear rates, dependable scheduling communication, screened staff appropriate to the service, a care contact, and a process for raising concerns. Changes in needs or schedule may affect staffing and cost and should be discussed promptly.