Is Private Duty Nursing Covered by Medicare?

Medicare is a federal health insurance program primarily for people aged 65 or older, some younger people with disabilities, and people with End-Stage Renal Disease. Many individuals wonder if Medicare covers private duty nursing, especially for continuous, personalized home care. Understanding Medicare’s specific regulations and distinctions between care types is important for navigating these financial considerations. The program has clear guidelines on what nursing services it will and will not pay for.

Defining Private Duty Nursing and Medicare’s Coverage Stance

Private duty nursing generally refers to one-on-one, continuous, and highly personalized nursing care provided to an individual, often at home. This care is typically for those with chronic conditions, complex medical needs, or individuals recovering from severe medical events requiring constant attention. Private duty nurses, who are licensed professionals such as Registered Nurses (RNs) or Licensed Practical Nurses (LPNs), manage tasks ranging from medication administration to ventilator care.

Medicare’s general stance is that private duty nursing, due to its continuous and individualized nature, does not typically qualify for reimbursement. The program primarily distinguishes between “skilled” medical care and “custodial” or “personal” care. Skilled care involves services that can only be performed safely and effectively by licensed healthcare professionals, such as wound care, injections, or physical therapy. In contrast, custodial care involves non-medical assistance with daily living activities, such as bathing, dressing, eating, or using the bathroom, and can be provided by non-licensed caregivers. Medicare typically does not cover long-term or continuous custodial care needs, viewing private duty nursing’s continuous model as beyond the scope of its home health benefit.

Nursing Services Covered by Medicare

Medicare does cover specific nursing services under certain defined circumstances, primarily when the care is medically necessary and skilled in nature. These services are typically short-term, rehabilitative, or medically required to treat an illness or injury.

One primary area of coverage is medically necessary skilled nursing care provided through a Medicare-certified home health agency. To qualify, an individual must be homebound, meaning it is a taxing effort to leave home, and require part-time or intermittent skilled nursing care or therapy services. A doctor must certify the need for these services as part of a physician-approved plan of care. Intermittent care means services are provided up to 8 hours a day for a maximum of 28 hours per week, though up to 35 hours per week may be covered for a short period.

Medicare also covers short-term skilled nursing care in a Skilled Nursing Facility (SNF) under specific conditions. This coverage is available following a qualifying inpatient hospital stay of at least three consecutive days, not including observation status days. The individual must be admitted to the SNF within 30 days of hospital discharge and require daily skilled nursing or rehabilitation services. Medicare Part A covers the full cost for the first 20 days in a SNF, and then a daily co-insurance amount applies from day 21 through day 100, which was $209.50 per day in 2025. After 100 days, Medicare coverage for SNF care ceases.

Nursing Services Not Covered by Medicare

Medicare generally does not cover services considered custodial or long-term in nature, which are often associated with comprehensive “private duty nursing.” Custodial care, which involves assistance with activities of daily living like bathing, dressing, and eating, is not covered by Medicare if it is the only care needed. These services can be performed by non-medical personnel and are not aimed at treating a specific medical condition.

Medicare specifically excludes payment for 24-hour-a-day care at home, home meal delivery, or homemaker services unrelated to a care plan. Furthermore, Medicare does not cover long-term care, which includes extended stays in nursing homes or assisted living facilities primarily for non-medical reasons. While Medicare may cover short-term skilled care in a nursing home following a hospital stay, it does not provide coverage for indefinite stays. Services from personal care aides who assist with non-medical needs are also not covered.

Alternative Funding for Private Duty Nursing

Given that Medicare typically does not cover continuous private duty nursing for long-term or custodial care, exploring alternative funding sources becomes imperative. Several options can help individuals manage the substantial costs associated with such care.

Medicaid, a joint federal and state program, can be a significant source of funding for long-term care and some personal care services, particularly for eligible low-income individuals. Eligibility requirements vary by state, but Medicaid often covers nursing facility care and home and community-based services that include personal care assistance.

Private long-term care insurance policies are designed specifically to cover costs not reimbursed by Medicare, including in-home care, assisted living, and nursing home care. These policies can help protect personal assets by providing financial protection against the high costs of extended care. Eligibility for benefits often triggers when an individual cannot perform a certain number of daily living activities.

Veterans’ benefits can also provide support for nursing or home care for eligible veterans. Programs offered through the Department of Veterans Affairs (VA) may include homemaker and home health aide services, skilled home health care, and in some cases, financial assistance for nursing home care. Additionally, many individuals resort to private pay, using personal savings, retirement funds, or other assets to cover the costs of private duty nursing. State and local programs may also offer assistance, and individuals are encouraged to explore these resources for potential financial aid.