Guides Private duty and personal care
Service-line guide
Private duty nursing and personal care
Private duty nursing is hours-based skilled nursing; personal care and non-medical home care are hours of hands-on help and household support. Neither is Medicare home health. They are licensed by the states, paid mostly by Medicaid, long-term-care insurance, the VA and private pay, and governed federally through Medicaid rules, electronic visit verification and federal wage law.
Educational summary, last reviewed October 17, 2026. Not legal advice — confirm with the state licensing agency or counsel.
Last reviewed October 17, 2026. 46 findings: 32 verified, 13 provisional, 1 disputed. 5 time-sensitive, flagged with a recheck date. How findings are sourced and labelled.
1What it is
Medicare home health pays for intermittent skilled visits. Private duty nursing is shifts of skilled nursing. Personal care is hours of help with activities of daily living. Companion and homemaker care is hours of supervision and household help. One agency often holds licenses for more than one of these, and the license category decides which payers it can bill.
Medicare home health requires the beneficiary to be confined to the home and to need intermittent skilled nursing, physical therapy, speech-language pathology or continuing occupational therapy, under a plan of care (42 CFR 409.42). It does not pay for continuous shift nursing or for personal care on its own. See the Medicare home health guide.
Source: 42 CFR 409.42 (eCFR)
Medicaid defines private duty nursing as nursing services for beneficiaries who need more individual and continuous care than a visiting nurse can give or than hospital or nursing facility staff routinely provide. A registered nurse or licensed practical nurse provides it under the direction of the beneficiary’s physician or other authorized practitioner; at state option it may be furnished in the home, a hospital or a skilled nursing facility (42 CFR 440.80).
Source: 42 CFR 440.80 (eCFR)
Medicaid state plan personal care services are furnished to a person who is not an inpatient or resident of a hospital, nursing facility, ICF/IID or institution for mental diseases. They are authorized by a physician under a plan of treatment or, at state option, under another state-approved service plan, and are provided by a qualified individual who is not a legally responsible relative, in the home and, at state option, other locations (42 CFR 440.167).
Source: 42 CFR 440.167 (eCFR)
One state’s license categories
VerifiedTexas issues home and community support services agency licenses in four categories: licensed and certified home health, licensed home health (each with or without a home dialysis designation), hospice, and personal assistance services (26 TAC §558.13). There is no separate private duty nursing category; shift nursing sits under a home health category.
In practice: The placement of shift nursing under the home health category is drawn from the category list, not from a separate rule. See Texas.
The 75-hour home health aide training standard, with at least 16 hours of supervised practical training or a state-approved competency evaluation, applies to Medicare-certified home health agencies (42 CFR 484.80). Training for non-medical and personal care aides is set by each state.
Source: 42 CFR 484.80 (eCFR)
2Who regulates it
The state licenses the agency (or does not), the state Medicaid agency and its operating agencies enroll and certify Medicaid providers under federal rules, and the U.S. Department of Labor enforces federal wage law.
Three state licensing patterns
ProvisionalStates follow three patterns for non-medical home care: a dedicated license (for example Washington, Texas personal assistance services, Illinois home services and California home care organizations), registration only (Florida homemaker and companion providers), and no state license for private-pay non-medical care, where Medicaid enrollment and waiver certification are the real gate. No authoritative 2026 count of states in each pattern was found.
Not yet confirmed — check with each state’s licensing agency.
In practice: Home health licensing by state is on the state home health license map.
Source: 26 TAC §558.13Fla. Stat. §400.509Vitable: Washington licensure (secondary)
Medicaid HCBS authorities
VerifiedMedicaid home and community-based services run under several authorities, each with its own rules: section 1915(c) waivers (42 CFR 441 Subpart G; institutional level of care and cost neutrality), 1915(i) state plan HCBS (Subpart M; needs-based criteria less stringent than institutional level of care), 1915(k) Community First Choice (Subpart K; attendant services with a 6-percentage-point FMAP increase), 1915(j) self-directed personal assistance (Subpart J), and section 1115 demonstrations.
Source: 42 CFR 441 Subpart G (eCFR)42 CFR 441 Subpart M (eCFR)42 CFR 441 Subpart K (eCFR)42 CFR 441 Subpart J (eCFR)
HCBS Settings Rule
ProvisionalHCBS settings must meet the requirements of 42 CFR 441.301(c)(4)–(5), with parallel provisions for 1915(i) and (k). The final rule was published January 16, 2014, and the transition period ended March 17, 2023.
Not yet confirmed — check with CMS.
In practice: The dates were not confirmed in the cited source.
Source: Medicaid.gov: Home and community-based services42 CFR 441 Subpart G (eCFR)
Where a state delivers HCBS through managed care plans, those plans run under the Medicaid managed care rules at 42 CFR Part 438, and agencies credential with each plan separately.
Source: 42 CFR Part 438 (eCFR)
Self-direction
ProvisionalUnder self-direction the participant may act as employer of record (with a fiscal or employer agent) or work through an agency-with-choice model; 1915(c), 1915(j), 1915(k) and section 1115 programs allow it (42 CFR 441 Subpart J).
Not yet confirmed — check with the state Medicaid agency.
In practice: The model names come from general practice and were not confirmed in the cited source.
Source: 42 CFR 441 Subpart J (eCFR)
3Federal rules
Two federal regimes reach these agencies directly: electronic visit verification for Medicaid visits, and federal minimum wage and overtime law. For home care overtime, the regulation in force, the Department of Labor’s enforcement policy and a pending proposal are three different things, set out separately below.
EVV: the federal deadlines
VerifiedSSA §1903(l), added by §12006(a) of the 21st Century Cures Act, requires states to use electronic visit verification for Medicaid personal care services by January 1, 2020 and for Medicaid home health care services by January 1, 2023, where the service involves an in-home visit. States that do not comply face incremental FMAP reductions of up to 1%, unless they made a good-faith effort and met unavoidable delays.
Source: Medicaid.gov: Electronic visit verification42 U.S.C. 1396b (SSA §1903)CMS Informational Bulletin, May 16, 2018
EVV: what must be verified
VerifiedAn EVV system must verify the type of service, the individual receiving it, the date, the location, the individual providing it, and the time the service begins and ends (42 U.S.C. 1396b(l)).
Source: 42 U.S.C. 1396b (SSA §1903)
The federal deadlines are not the dates every state went live. CMS publishes each state’s home health care services compliance status as of January 1, 2024, and some states, Texas among them, had extensions to January 1, 2024. Each state sets its own EVV system and go-live schedule.
In practice: EVV is a Medicaid requirement; Medicare home health does not require it.
Source: Medicaid.gov: EVV compliance status, home health care servicesCMS Informational Bulletin, May 16, 2018Texas Register, December 8, 2023: adopted rules
The Department of Labor’s current regulations are the 2013 final rule, Application of the Fair Labor Standards Act to Domestic Service (78 FR 60454, October 1, 2013). It bars third-party employers, such as home care agencies, from claiming the companionship services exemption (minimum wage and overtime) or the live-in domestic service exemption (overtime), amending 29 CFR 552.109(a) and (c), and narrows “companionship services” in 29 CFR 552.6, including a limit of 20% of weekly hours on care. The rule has not been repealed.
Source: DOL Field Assistance Bulletin 2025-4Federal Register 2025-12316: Application of the FLSA to Domestic Service (90 FR 28976)DOL: Domestic service and home care FAQ
Field Assistance Bulletin 2025-4 (July 25, 2025) directs Wage and Hour Division staff to stop applying the 2013 rule, including in open cases, and not to investigate third-party employers that claim the companionship or live-in exemptions. It applies until the effective date of any final rule. It states that it “does not alter any statutory or regulatory requirements”, and that home care by registered nurses or licensed practical nurses is not affected and is not exempt.
Time-sensitive. The bulletin ends when a final rule takes effect; recheck the Federal Register and docket WHD-2025-0001 by January 2027.
The Department of Labor proposed on July 2, 2025 (90 FR 28976) to rescind the 2013 rule, restore the third-party employer exemptions and drop the 20% care-time limit. Comments closed September 2, 2025; the docket is WHD-2025-0001. A proposal does not change the regulation.
Source: Federal Register 2025-12316: Application of the FLSA to Domestic Service (90 FR 28976)
Overtime: final rule status
ProvisionalNo final rule was found in the sources reviewed for this guide. Law-firm analyses describe the 2013 rule as still on the books.
Not yet confirmed — check with the U.S. Department of Labor.
Time-sensitive. Recheck the Federal Register and docket WHD-2025-0001 by January 2027.
Source: Akerman: companionship and live-in exemptions (secondary)Jackson Lewis: DOL proposal (secondary)Federal Register 2025-12316: Application of the FLSA to Domestic Service (90 FR 28976)
State wage and overtime law
ProvisionalA change to the federal exemptions would only affect agencies in states whose own exemptions mirror the FLSA. Workers in states with their own overtime protections keep them.
Not yet confirmed — check with the state labor department.
Source: Frier Levitt: proposed rule and state law (secondary)Jackson Lewis: DOL proposal (secondary)
4Payment
Medicaid is the main payer for private duty nursing and personal care, through the state plan, EPSDT for children and HCBS programs. Long-term-care insurance, the VA, commercial plans and private pay make up the rest.
Private duty nursing is listed among the Medicaid benefits in SSA §1905(a)(8). For adults it is an optional state plan benefit: a state may cover it but is not required to.
For Medicaid-eligible children and youth under 21, EPSDT requires the state to cover any §1905(a) service, private duty nursing included, that is necessary “to correct or ameliorate” a physical or mental illness or condition, “whether or not such services are covered under the State plan” (SSA §1905(r)(5)). The test is medical necessity for the individual child; the statute does not make any service automatic.
In practice the state Medicaid agency or the child’s Medicaid managed care plan decides medical necessity case by case and authorizes a number of nursing hours, usually on a practitioner’s order and supporting clinical documentation. Pediatric private duty nursing agencies depend mostly on these EPSDT authorizations. How each state documents need and authorizes hours was not researched for this guide.
Not yet confirmed — check with the state Medicaid agency.
Personal care is paid through the state plan benefit (42 CFR 440.167) or through HCBS programs such as 1915(c) waivers and 1915(k) Community First Choice. Which route applies depends on the state and on the participant’s eligibility.
Source: 42 CFR 440.167 (eCFR)42 CFR 441 Subpart G (eCFR)42 CFR 441 Subpart K (eCFR)
The 2025 budget law (H.R. 1) creates a standalone 1915(c) waiver option that does not require a nursing facility or ICF/IID level of care, using state needs-based criteria. States may submit these waivers from July 1, 2028, subject to cost neutrality, a showing that waits on other waivers will not grow, and at least annual cost and utilization reporting. Sources disagree on the section number of the law.
Not yet confirmed — check with CMS and the enrolled text of H.R. 1 on congress.gov.
Source: NHeLP: New 1915(c) waiver opportunity under OBBBA (secondary)NASDDDS: Non-LOC waiver factsheet (secondary)
A tax-qualified long-term-care insurance policy pays when the insured cannot perform at least 2 of 6 activities of daily living or has severe cognitive impairment (26 U.S.C. 7702B(c)). How commercial health plans cover private duty nursing was not researched for this guide.
Source: 26 U.S.C. 7702B
5The 80% direct-care compensation rule
The 2024 Medicaid Access Rule added a minimum share of payment that must reach direct care workers. It covers specific services under specific HCBS authorities, not all Medicaid home care, and its minimum does not apply until 2030.
What the rule requires
VerifiedThe 2024 final rule, Ensuring Access to Medicaid Services (89 FR 40542, May 10, 2024), requires each provider to spend at least 80% of the Medicaid payments it receives for homemaker, home health aide and personal care services on compensation for the direct care workers who furnish them (42 CFR 441.302(k)(3)). The requirement is stated for those services when authorized under section 1915(c) (441.302(k)(2)). Compensation means wages and other FLSA remuneration, benefits, and, for 1915(c) services, the employer share of payroll taxes; training, travel and protective-equipment costs are excluded from the calculation.
In practice: States may set a different level for small providers and exempt providers facing extraordinary circumstances, each through a public process (441.302(k)(4)–(5)).
Source: 42 CFR 441 Subpart G (eCFR)Federal Register 2024-08363: Ensuring Access to Medicaid Services (89 FR 40542)ACL: Medicaid Access Rule
What the rule does not cover
VerifiedThe minimum does not reach every Medicaid home care service. CMS guidance states that the related reporting requirement “does not apply to section 1905(a) services”, such as state plan personal care, home health and case management. Private duty nursing is not one of the covered services. Payment data for self-directed services where the beneficiary sets the worker’s rate is excluded, and Indian Health Service and Tribal programs are exempt.
Source: CMS SMD 26-005: Direct Care Worker Compensation Reporting Requirement (October 9, 2026)42 CFR 441 Subpart G (eCFR)
When it applies
VerifiedStates must report the share of payments going to direct care workers from July 9, 2028 (42 CFR 441.311(e)). The 80% minimum applies from July 9, 2030, six years after July 9, 2024; for managed care, from the first rating period beginning on or after that date (441.302(k)(8)).
Source: 42 CFR 441 Subpart G (eCFR)CMS SMD 26-005: Direct Care Worker Compensation Reporting Requirement (October 9, 2026)NHeLP: Access Rule overview (secondary)
State Medicaid Director Letter SMD 26-005 explains the reporting requirement. States must tell CMS how they will be ready by July 9, 2027. Reporting covers homemaker, home health aide, personal care and habilitation services under sections 1915(c), (i), (j) and (k) and section 1115 demonstrations, in fee-for-service and managed care, separately for each service. The measurement period is the prior calendar year, so 2028 reports cover January 1 to December 31, 2027. Overtime pay counts as compensation, and providers may not count pay for administrative work unrelated to direct care. CMS expects a reporting form by September 1, 2027. The letter addresses reporting only; it does not change the 80% minimum.
Time-sensitive. Readiness reports are due July 9, 2027; recheck medicaid.gov for the reporting form by September 1, 2027.
Source: CMS SMD 26-005: Direct Care Worker Compensation Reporting Requirement (October 9, 2026)
A possible revision is pending, not final
ProvisionalTrade reports say CMS has signaled a proposed rule that could revise or rescind provisions of the 2024 rules, including the 80% requirement. No proposed or final rule was found in the Federal Register in the sources reviewed, and the current eCFR text of 42 CFR 441.302(k) still contains the requirement. The rule has not been rescinded.
Not yet confirmed — check with CMS.
Time-sensitive. Recheck the Federal Register and reginfo.gov for an amendment to 42 CFR 441.302(k) by January 2027.
Source: Paradigm Senior Services: CMS signals potential reversal (secondary)McKnight’s Home Care (secondary)42 CFR 441 Subpart G (eCFR)
Other Access Rule dates moved in 2026
ProvisionalA CMS informational bulletin dated February 26, 2026 is reported to have postponed enforcement of the HCBS fee-for-service grievance system from July 9, 2026 to December 31, 2027, and to relax Interested Parties Advisory Group convening deadlines. Neither change is reported to affect the 80% requirement.
Not yet confirmed — check with CMS.
Time-sensitive. The bulletin itself was not reviewed; recheck medicaid.gov before relying on these dates.
6How states differ
Licensing, aide training and background checks for non-medical home care are state law. The examples below are not a 50-state list.
Texas licenses personal assistance services as one of its home and community support services agency categories, through the HHS licensure and certification unit; an applicant may request one or more categories (26 TAC §558.13).
In Florida, a provider of companion or homemaker services that does not provide home health services is exempt from home health licensure but must register with AHCA; providers under contract with the Agency for Persons with Disabilities serving only people with developmental disabilities are exempt (Fla. Stat. §400.509). Registration uses AHCA Form 3110-1003 with a non-refundable fee and lasts up to 2 years. Licensed home health agencies and nurse registries are exempt from it (R. 59A-8.025).
In practice: The rule copy cited may not be the latest version.
California licenses home care organizations under the Home Care Services Consumer Protection Act (Health and Safety Code §1796.10 et seq.), and affiliated aides register on the Home Care Aide Registry. Aides need 5 hours of entry-level training before client contact (2 hours of orientation, 3 of safety) and at least 5 hours each year; SB 412 (2025) kept those hours and set content requirements for annual training (§1796.44).
Not yet confirmed — check with the California Department of Social Services.
In Washington, home care aides are governed by chapter 18.88B RCW and chapter 246-980 WAC. Certification requires entry-level training under RCW 74.39A.073, a certification exam and AIDS education (WAC 246-980-040).
Washington: in-home services license
ProvisionalThe Department of Health licenses in-home services agencies under RCW 70.127 and WAC 246-335, with separate categories for home care, home health and hospice. An initial license is reported to run 12 months and later licenses 2 years. Reported training hours, fees and bond amounts were not confirmed.
Not yet confirmed — check with the Washington State Department of Health.
Illinois: home services agencies
DisputedIllinois licenses non-medical home services agencies through IDPH under 77 Ill. Adm. Code 245; workers not otherwise licensed must clear the Health Care Worker Background Check Act. Sources conflict on initial training hours: one reports 8 hours (4 before the first assignment) plus 8 each year, while the rule text refers to competency testing after two five-hour blocks.
Not yet confirmed — check with the Illinois Department of Public Health.
Source: 77 Ill. Adm. Code 245.71 (ILGA)Vitable: Illinois caregiver training (secondary)
Arizona (home health only), Alabama and Iowa are reported not to license private-pay non-medical home care at the state level. Agencies serving Medicaid participants still face Medicaid enrollment and certification there.
Not yet confirmed — check with each state’s licensing agency.
Source: Vitable: Arizona (secondary)Vitable: Alabama (secondary)Vitable: Iowa (secondary)
7How to start
A typical order of steps
ProvisionalThe cited requirements put the work in this order: form the entity; obtain the state license or registration for each service category, or confirm none is needed; obtain an NPI; enroll as a Medicaid provider; certify as a waiver provider with the operating agency; credential with Medicaid managed care plans; and connect to the state’s EVV system. No single official checklist sets this order.
Not yet confirmed — check with the state Medicaid agency.
In practice: License categories differ by state; see the state home health license map and each state page.
Source: 26 TAC §558.1342 CFR 455 Subpart E (eCFR)Medicaid.gov: Electronic visit verification
Medicaid provider screening
VerifiedMedicaid enrollment follows risk-based screening: site visits for moderate- and high-risk categories, and fingerprinting for high-risk providers (42 CFR 455 Subpart E).
Source: 42 CFR 455 Subpart E (eCFR)
Connecting to EVV
VerifiedAgencies billing Medicaid for personal care or home health care visits must record them through the state’s EVV arrangement, so EVV setup belongs in the start-up plan.
Source: Medicaid.gov: Electronic visit verification42 U.S.C. 1396b (SSA §1903)
Example: starting in Texas
VerifiedIn Texas, the applicant requests one or more license categories (personal assistance services for non-medical care, a home health category for nursing) from the HHS licensure and certification unit (26 TAC §558.13).
8Common pitfalls
Medicare home health covers intermittent skilled care for homebound beneficiaries (42 CFR 409.42). Shift nursing and personal care need another payer.
Source: 42 CFR 409.42 (eCFR)
EPSDT covers private duty nursing for an eligible child only when it is necessary to correct or ameliorate a condition (SSA §1905(r)(5)). Each case still turns on medical necessity and the state’s or plan’s authorization of hours.
Misreading the 80% rule
VerifiedThe 80% minimum covers homemaker, home health aide and personal care services under the HCBS authorities the rule names, not all Medicaid home care, and it applies from July 9, 2030. It remains in the regulation; a signaled revision is not a rescission.
Source: 42 CFR 441 Subpart G (eCFR)CMS SMD 26-005: Direct Care Worker Compensation Reporting Requirement (October 9, 2026)
FAB 2025-4 suspends federal enforcement of the 2013 Home Care Rule; it does not repeal it and states that it “does not alter any statutory or regulatory requirements”. Nurses are not exempt, and state overtime law still applies where the state has its own.
The federal EVV deadlines (January 1, 2020 for personal care; January 1, 2023 for home health care) are not each state’s go-live date. The state’s own schedule and system govern day to day.
Source: Medicaid.gov: Electronic visit verificationMedicaid.gov: EVV compliance status, home health care services
Official sources
- 42 CFR 409.42 (eCFR)
- 42 CFR 440.80 (eCFR)
- 42 CFR 440.167 (eCFR)
- 26 TAC §558.13
- Texas HHS: HCSSA licensing
- 42 CFR 484.80 (eCFR)
- Fla. Stat. §400.509
- Vitable: Washington licensure (secondary)
- 42 CFR 441 Subpart G (eCFR)
- 42 CFR 441 Subpart M (eCFR)
- 42 CFR 441 Subpart K (eCFR)
- 42 CFR 441 Subpart J (eCFR)
- Medicaid.gov: Home and community-based services
- 42 CFR Part 438 (eCFR)
- Medicaid.gov: Electronic visit verification
- 42 U.S.C. 1396b (SSA §1903)
- CMS Informational Bulletin, May 16, 2018
- Medicaid.gov: EVV compliance status, home health care services
- Texas Register, December 8, 2023: adopted rules
- DOL Field Assistance Bulletin 2025-4
- Federal Register 2025-12316: Application of the FLSA to Domestic Service (90 FR 28976)
- DOL: Domestic service and home care FAQ
- Akerman: companionship and live-in exemptions (secondary)
- Jackson Lewis: DOL proposal (secondary)
- Frier Levitt: proposed rule and state law (secondary)
- 42 U.S.C. 1396d (SSA §1905)
- Medicaid.gov: EPSDT
- NHeLP: New 1915(c) waiver opportunity under OBBBA (secondary)
- NASDDDS: Non-LOC waiver factsheet (secondary)
- 26 U.S.C. 7702B
- Federal Register 2024-08363: Ensuring Access to Medicaid Services (89 FR 40542)
- ACL: Medicaid Access Rule
- CMS SMD 26-005: Direct Care Worker Compensation Reporting Requirement (October 9, 2026)
- NHeLP: Access Rule overview (secondary)
- Paradigm Senior Services: CMS signals potential reversal (secondary)
- McKnight’s Home Care (secondary)
- Soriaga CPA: Medicaid 80/20 rule (secondary)
- Fla. Admin. Code R. 59A-8.025
- California SB 412 (2025), chaptered text (LegiScan)
- Washington DOH: home care aide laws and rules
- 77 Ill. Adm. Code 245.71 (ILGA)
- Vitable: Illinois caregiver training (secondary)
- Vitable: Arizona (secondary)
- Vitable: Alabama (secondary)
- Vitable: Iowa (secondary)
- 42 CFR 455 Subpart E (eCFR)
Revision history
| Date | Change |
|---|---|
| 2026-10-17 | First published |
About this guide. Published and maintained by Paloma Health Technologies; Findings are cited to official sources, dated and status-labelled; see the editorial policy. Educational summary, last reviewed October 17, 2026. Not legal advice — confirm with the state licensing agency or counsel.
Questions
Private duty and personal care: common questions
Does Medicare pay for private duty nursing or personal care?
No. Medicare home health covers intermittent skilled care for homebound beneficiaries under a plan of care (42 CFR 409.42). Continuous shift nursing and personal care are paid mostly by Medicaid, long-term-care insurance, the VA and private pay.
Must every state Medicaid program cover private duty nursing?
For adults, no: it is an optional state plan benefit. For Medicaid-eligible children and youth under 21, EPSDT requires coverage of private duty nursing when it is necessary to correct or ameliorate a condition, even if the state does not cover it for adults. Coverage is decided case by case on medical necessity.
Does the 80% direct-care compensation rule apply to all Medicaid home care?
No. It covers homemaker, home health aide and personal care services under the HCBS authorities the rule names, and CMS guidance says the related reporting does not apply to section 1905(a) state plan services. State reporting begins July 9, 2028 and the 80% minimum applies from July 9, 2030.
Has the 2013 Home Care Rule on overtime been repealed?
No. It remains the Department of Labor’s current regulation. Since July 25, 2025 the department does not enforce it (FAB 2025-4), and a July 2025 proposal would rescind it, but a proposal does not change the regulation.
When did EVV become required for Medicaid personal care and home health?
The federal deadlines were January 1, 2020 for personal care services and January 1, 2023 for home health care services (SSA §1903(l)). State go-live dates differ, and some states had extensions to January 1, 2024.