Medicaid Self-Direction & Consumer-Directed Services (2026)

If you have been trying to work out how a relative could be paid to care for your mom or dad, the tangle of program names alone is enough to stop most families cold. Underneath all of them sits one mechanism: Medicaid self-direction is the reason most family caregivers can be paid at all. It lets the person receiving care hire and direct their own caregiver, including a relative.1

It goes by many names: consumer direction, CDPAP in New York, CDASS in Colorado, IRIS in Wisconsin, CFSS in Minnesota. The mechanics are the same everywhere, and understanding them is what gets you paid. This guide explains how self-direction works, the federal rules behind it, who can be hired, and how to get started.

The details vary by state, so always check your state's guide for the specific program and rules.

How Medicaid Self-Direction Lets You Choose Your Caregiver

Most people picture Medicaid home care as an agency sending a stranger to the house on the agency's schedule. Self-direction flips that. Under a self-directed (or consumer-directed) model, the person receiving care, or their chosen representative, decides who provides their care and how. The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicaid, describes self-direction as promoting "personal choice and control over the delivery of waiver and state plan services."1

That control is what allows a family member to be hired and paid. Instead of an agency assigning a worker, you, or your loved one, can choose your own daughter, sibling, friend, or, in some states, spouse.

The Two Kinds of Authority: Employer and Budget

CMS divides self-direction into two types of decision-making power. A program may offer one or both:1

• Employer authority. You recruit, hire, train, supervise, and dismiss your own workers, functioning as the common-law employer (or co-employer with a support agency). This is the authority that lets you put a specific relative on payroll. Colorado's CDASS and New York's CDPAP are examples.
• Budget authority. You receive an individual budget of Medicaid dollars and decide how to spend it across services, goods, and workers, within program rules. New Mexico's Mi Via is an example.

Many programs combine the two: you both hire your own worker and manage a budget.

Which Federal Rules Power Medicaid Self-Direction?

States build their self-directed programs on top of one or more federal Medicaid authorities. You do not need to master these, but recognizing them helps you understand your state's program:1

• 1915(c) Home and Community-Based Services (HCBS) waivers are the most common vehicle; most state waivers offer a self-directed option.
• Section 1915(j) Self-Directed Personal Assistance Services is a state plan option specifically for self-direction. Under 1915(j), a state may choose to allow paid legally liable relatives, such as parents or spouses.
• 1915(k) Community First Choice (CFC) is a state plan entitlement, with no enrollment waitlist, for attendant services, almost always self-directed.
• 1915(i) HCBS and 1115 demonstrations are additional pathways some states use.

During the COVID-19 public health emergency, many states used Appendix K authority to temporarily let additional family members, and in some states legally responsible relatives, deliver paid HCBS. Some states later made those flexibilities permanent; others let them expire.1

Can a Family Member Be Your Paid Caregiver?

This is where state rules diverge the most, and where the stakes get personal. If your family relies on a spouse or an adult child as the primary caregiver, whether your state's rules line up with your situation can decide whether that care is paid work or an unpaid sacrifice.

• Non-spouse relatives and friends, such as an adult child, sibling, or friend, can be the paid worker in nearly every state's self-directed program.1
• Spouses can be paid in some states and are barred in many others. Whether a spouse, a legally responsible individual, can be hired is a state option, not a federal guarantee.1
• Parents of minor children are treated like spouses, as legally responsible individuals, and are often barred unless the state opted in under 1915(j).1

Because this varies so much, the only reliable answer is your state's guide. See How to Get Paid as a Family Caregiver and pick your state.

Who Handles Taxes and Payroll?

Becoming an employer sounds daunting, especially on top of everything else you are already managing. Here is the relief: you do not run payroll yourself. A Financial Management Service (FMS) agency, sometimes called a fiscal intermediary or fiscal employer agent, handles payroll processing, tax withholding and reporting, and the employer paperwork on your behalf. You direct the work; the FMS handles the money.1

How Do You Get Started with Self-Direction?

You do not apply for "self-direction" on its own. It is an option inside your state's Medicaid home care programs, so the path runs through them. Here is the usual sequence:

If you are not sure where your state's program lives, start at the federal level. CMS lists self-directed services at medicaid.gov, or call the Eldercare Locator at 1-800-677-1116 to reach your local Area Agency on Aging.2

Learn More

Find personalized help setting up self-directed care at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.