Insurance & payment
How paying for home nursing usually works
The honest version: what determines whether your child gets nursing hours, who decides, and where families most often get stuck.
Three things decide what you get
1. Medical necessity. Your child’s physician documents the skilled nursing they need: what has to be done, how often, and why it requires a licensed nurse rather than a caregiver.
2. The payer’s authorization. Medicaid or the managed care plan reviews that documentation and authorizes a number of hours. This is the step families most often get stuck at, and the one appeals exist for.
3. Staffing. Authorized hours only become real care when there is a nurse to work them. An agency that accepts a case it cannot staff has helped nobody.
We will tell you which of the three is holding your child’s care up. It is usually not the one families expect.
Plans we work with
Which plans we accept
The list of Medicaid programmes and managed care plans we hold contracts with is still being confirmed, so we have not published it here yet.
We would rather not name a payer we cannot actually bill — it raises enquiries we then have to turn away, and payers hold us to what we publish. Ask us about your plan and we will tell you directly whether we can work with it.
Where to push
If your hours do not match your child’s needs
Families have more leverage here than they are usually told.
- Ask your child’s physician exactly what they documented, and whether it reflects the current situation
- Ask your case manager which criteria the decision was made against
- Ask for the denial or authorization in writing, with the reasons
- Ask what additional documentation would support an appeal: nursing notes often help
- Keep your own record of the nights that went badly; specifics carry more weight than "it is very hard"
Questions
Questions about coverage
Does Medicaid cover private duty nursing for children?
In general, state Medicaid programmes cover medically necessary skilled nursing at home for children who qualify, under the federal EPSDT benefit. What that means in practice (how many hours, which programme, what documentation) is set by your state and by your child’s plan.
What does "medically necessary" mean here?
It means your child’s physician has documented that they need skilled nursing care, and the payer agrees. It is a clinical judgement written down, not a form you fill in yourself.
What if we are denied the hours we asked for?
Denials can be appealed, and appeals succeed often enough to be worth making. Your child’s physician and case manager lead that process; ask them what documentation would strengthen it.
Will we be charged for anything?
You should not be billed for authorized nursing hours covered by your plan. If anyone tells you otherwise, ask for it in writing before agreeing to anything.
Content last reviewed . This page is general information, not medical advice — please talk to your child’s physician about their care.
Not sure what your plan covers?
Tell us what you have and we will tell you what we know, including when the answer is “ask your case manager”.