Who Pays for a Private Duty Nurse
Medicare does not pay for private duty nursing. The usual payers are Medicaid (required for children under 21 when medically necessary, and available to some adults through the state plan or a waiver), private health insurance (often limited, with prior authorization), long-term care insurance, the VA, and the family's own money. Most families combine more than one.
Medicare: not covered
Medicare's list of what it does not cover includes private-duty nursing, and its home health benefit does not pay for 24-hour-a-day care at home. What Medicare does cover is part-time, intermittent home health visits for homebound patients (see private duty nursing vs home health). Medicare Advantage plans must cover what Original Medicare covers and may add extras, so if you have one, ask the plan in writing whether any in-home nursing benefit applies. Check: Medicare.gov, home health services.
Medicaid and its waivers
- Children under 21: Medicaid's EPSDT benefit requires states to cover medically necessary services, and private duty nursing is one of the services federal law lists. If a child's doctor documents the need, the state must decide on that basis. Read the rule on Medicaid.gov's EPSDT page.
- Children whose parents earn too much for Medicaid: many states offer a route based on the child's own income, under names like TEFRA, Katie Beckett or a children's waiver. In the Southeast, these include TEFRA in South Carolina, CAP/C in North Carolina, GAPP in Georgia and Katie Beckett in Tennessee.
- Adults: private duty nursing is an optional Medicaid benefit, so it depends on your state. Many states offer it through home and community-based services (HCBS) waivers, which can have waiting lists. Some let families self-direct care and hire their own nurse.
- Where to check: your state Medicaid agency, listed on Medicaid.gov.
Private health insurance
Employer and marketplace plans vary widely. Some cover private duty nursing for a limited number of hours or days when medically necessary; many exclude it or cover it only as an alternative to a hospital stay. The plan's Summary of Benefits and Coverage and its full policy document say which; search them for "private duty nursing" and "custodial care". Expect prior authorization and periodic re-review.
Long-term care insurance
Long-term care policies often pay for in-home care, including nursing shifts, once the policyholder meets the policy's benefit trigger. For tax-qualified policies that is typically needing help with two of six activities of daily living for at least 90 days, or a severe cognitive impairment. Policies usually have an elimination period (days you pay before benefits start) and a daily or monthly maximum. Some reimburse only licensed agencies.
Veterans
The VA can authorize home care for enrolled veterans through its own programs and through community care. Ask the veteran's VA primary care team about skilled home care and community care referrals, and see VA geriatrics and extended care.
Self-pay
Families paying themselves get the most choice of provider. Nursing services can count as medical expenses under IRS Publication 502, which matters for tax deductions and for paying from an HSA or FSA. If you hire a nurse directly, IRS Publication 926 covers your duties as a household employer.
Questions to ask each payer
- Medicaid: Is private duty nursing covered for this patient, under the state plan, EPSDT or a waiver?How to check: Ask for the program name and the policy section, and whether there is a waiting list.
- Medicaid: How many hours a week can be approved, and how are hours decided?How to check: Ask for the assessment tool or criteria and how to appeal a denial or a cut in hours.
- Private insurance: Does the plan cover private duty nursing, and what are the limits?How to check: Get the answer in writing with the policy wording, the number of hours or visits a year, and any lifetime cap.
- Private insurance: Is prior authorization required, and which providers are in network?How to check: Ask for a reference number for the call and a list of in-network private duty providers near you.
- Long-term care insurance: Has the benefit trigger been met, and when does the elimination period end?How to check: Ask the insurer what documentation the doctor must send and whether care must come from a licensed agency.
- Long-term care insurance: What is the daily or monthly maximum, and does the insurer pay the provider directly?How to check: Compare the maximum against written quotes so you know the gap you will pay.
- VA: Is the veteran eligible for skilled home care or community care for nursing hours?How to check: Ask the VA care team to place the referral and tell you which local providers accept it.
- Any provider you pay yourself: What is the hourly rate, minimum shift and overnight, weekend and holiday rate?How to check: Get it in writing before the first shift, with any deposit, fee or cancellation terms.