In Pennsylvania, a child generally qualifies for private duty nursing when the child is under 21 and covered by Medical Assistance (Medicaid). The child must also need skilled nursing that is more individual and continuous than a visiting nurse can give. A doctor’s order and proof of medical necessity decide the rest.
This guide explains those rules in plain English. It also covers the paperwork that helps and how private duty pediatric nursing in Philadelphia, PA works. It is educational, not medical or legal advice. Your child’s doctor and health plan make the final call.
What Is Private Duty Nursing for Children?
Private duty nursing, often called shift nursing, is one-on-one skilled nursing at home. Pennsylvania’s Department of Human Services describes it as skilled nursing for members under 21 who need more individual and continuous care than a visiting nurse or hospital staff routinely provide.
A licensed registered nurse (RN) or licensed practical nurse (LPN) delivers it. The nurse works for a home health agency under the direction of the child’s physician.
It differs from two other services families often confuse with it:
| Service | What it covers | Who provides it |
|---|---|---|
| Private duty nursing | Continuous skilled nursing care | RN or LPN from a home health agency |
| Home health nursing | Part-time or intermittent nursing visits | Visiting nurse |
| Personal care / home health aide | Help with daily tasks such as eating, bathing, and dressing | Aide |
A child may need more than one of these. The label matters because each has different approval rules.
What Are the Basic Requirements?
Health plans review each request individually. Most reviews start with five questions:
- Is your child under 21? The state guidance covers medically necessary services for Medical Assistance members under 21.
- Does your child have Medical Assistance coverage? In HealthChoices, the physical health plan must provide all medically necessary covered services for eligible members under 21. Private insurance rules vary, so call your plan.
- Does your child need skilled nursing? The care must call for a nurse’s training, not just supervision.
- Does a physician direct the care? Private duty nursing happens under the direction of the child’s doctor.
- Is it medically necessary? Plans must review every request using the medical necessity definition in the HealthChoices Agreement.
Which Medical Needs Lead Families to Ask About It?
The state guidance reviewed for this article does not list qualifying diagnoses. It tells plans to judge each request on medical necessity.
Local agencies do describe the children they serve. One Pennsylvania agency lists tracheostomies, ventilators, and tube feedings among the medically complex needs it supports. A Philadelphia-area nursing listing mentions children with seizure disorders, developmental delays, autism, or feeding tube needs.
A diagnosis alone does not settle the question. What matters is the care your child needs hour to hour, and whether a nurse must provide it.
How Do Plans Decide How Many Hours Your Child Gets?
Pennsylvania’s rules protect families from some common denials. Here is what plans must follow:
- No minimum hours. A plan cannot require a set block, such as four continuous hours, before it approves care.
- A parent at home is not an automatic “no.” The plan must show that the parent is actually able and available to give the care. It must weigh work schedules, sleep, and other responsibilities.
- Parents have other jobs. Those duties include household tasks, coordinating care, and looking after other children.
- School plans don’t cancel nursing. A plan cannot deny care because it believes an IEP or Section 504 Plan should cover it.
- Denials need reasons. A denial notice must explain the specific reasons the service was judged not medically necessary.
Parents are not 24-hour machines. The state’s rules say so, in more formal language.
What Paperwork Strengthens a Request?
Plans decide based on documents. A Letter of Medical Necessity and a plan of care are the key pieces. They should show the diagnosis, the course of treatment, and the level of care.
Gather these before you apply:
- A Letter of Medical Necessity from your child’s doctor
- The current plan of care or treatment plan
- A list of your child’s medications, equipment, and daily nursing tasks
- Caregiver information, such as work schedules and household responsibilities, if the plan asks
- Recent hospital discharge notes
If something is missing, the plan should contact the ordering provider, and sometimes the family, before it sends a request-for-information letter. Answer fast. Delays cost hours of care.
How Do You Start Private Duty Pediatric Nursing in Philadelphia, PA?
Follow these five steps:
- Talk with your child’s doctor. Ask whether your child needs skilled nursing at home and for how many hours.
- Call your health plan. Use the number on the member card. Plans may require prior authorization for skilled nursing, with state approval of their policy. Ask how that process works.
- Choose a home health agency with a pediatric nursing team. The agency must provide qualified, trained, safe staff and supervise them. Compare home health agencies in Philadelphia before you decide.
- Submit the paperwork. Your doctor and agency send the Letter of Medical Necessity and plan of care.
- Respond to follow-up questions. Keep your phone nearby.
Does Private Duty Nursing Cover School and Outings?
Sometimes. Nursing can continue outside the home when normal life activities take the child out, such as school. The child must first be eligible for private duty nursing in the home, hospital, or nursing facility.
Ask your plan how it handles school days before the school year starts.
How Does EldaCare Support Children and Families in Philadelphia?
EldaCare Home Health Services serves families across Philadelphia, Bucks, Montgomery, Chester, and Delaware counties. Its pediatric nursing team provides family-centered care for children with medical complexities and disabilities. It also supports children and adults with developmental delays.
What families can expect:
- Nurse supervision: Registered nurses oversee all home care services.
- Accreditation: EldaCare is ACHC accredited.
- Always reachable: It offers 24/7 on-call service.
- Family training: It will train and guide family members who want to help care for a loved one.
- Insurance: It lists Medicaid among its accepted insurance partners.
Plans and authorization rules differ, so confirm coverage for your child’s plan before care starts. Browse the full list of services to see what fits.
Frequently Asked Questions
Does my child need a specific diagnosis to qualify?
No fixed diagnosis list appears in Pennsylvania’s state guidance. Plans review each request for medical necessity.
Is there a minimum number of hours?
No. A plan cannot require a minimum number of hours before approving care.
Can the plan deny nursing because I’m home?
Not automatically. The plan must show that you are able and available to give the care your child needs.
Who provides the nursing?
A licensed RN or LPN employed by a home health agency, under a physician’s direction.
What if my child’s plan denies the request?
The denial notice must explain the specific reasons. Ask your agency and your child’s doctor about next steps, including appeals.
Have more questions? Visit EldaCare Home Health Services.
Talk With a Pediatric Nursing Team
Every child’s needs are different. Call +1 (267) 996-4393 or request a free consultation to ask about private duty pediatric nursing in Philadelphia, PA.