How to Get Paid as a Family Caregiver in North Dakota (2026)

Figuring out how to get paid as a family caregiver in North Dakota comes down to two systems: Medicaid home and community-based services (HCBS) waivers and the VA. North Dakota's consolidated HCBS waiver, run by the ND Department of Health and Human Services (NDDHHS), includes family personal care, which lets the care recipient choose a spouse or a close relative such as a parent, adult child or adult sibling as the paid provider, and payment goes only to a legal spouse or family member who lives in the same home.1 For veteran families, VA's caregiver stipend can pay a family caregiver, including a spouse.2

The Program of Comprehensive Assistance for Family Caregivers pays a monthly stipend to an eligible veteran's approved Primary Family Caregiver, and a spouse can serve as that caregiver.2 VA Aid and Attendance provides up to $34,488 per year for a veteran with one dependent in 2026.3

The Short Version

If the care recipient is a veteran, check the VA programs first. PCAFC pays an approved Primary Family Caregiver a monthly stipend; the caregiver must be at least 18 and either a spouse or other family member, or someone who lives (or is willing to live) full time with the veteran.2 Veteran-Directed Care, where a VA medical center offers it, gives the veteran a flexible budget for services and lets them hire their own personal care aides, which might include a family member.4 Aid and Attendance adds to the monthly pension of a veteran who already qualifies for a VA pension, and the veteran can put that money toward a family caregiver.2

If the care recipient qualifies for North Dakota's consolidated HCBS waiver, family personal care can pay a spouse or close relative who lives in the same home, once that relative enrolls as a Qualified Service Provider (QSP).1

If neither VA benefits nor Medicaid applies, the family can pay a relative privately. North Dakota Medicaid reviews asset transfers over the prior five years,1 so put the arrangement in writing and keep records of the care if Medicaid might be needed later.

What North Dakota Offers

Home and Community-Based Services (HCBS) Waiver

North Dakota's Medicaid 1915(c) HCBS waiver, renewed effective January 1, 2026, serves people 65 or older, and people ages 18 to 64 with physical or other disabilities, who meet a nursing facility level of care. CMS's list of every North Dakota 1915(c) waiver, active and terminated, shows no separately named Elderly and Disabled (E&D) waiver and no standalone Traumatic Brain Injury (TBI) waiver. Covered services include waiver personal care, family personal care, homemaker, respite care, chore, adult day care, home delivered meals, and other community supports. Each person's waiver services are capped at the highest monthly rate allowed to a nursing facility, though anyone can ask for a reasonable modification above it. In its 2026 renewal application, the state reported that it has no waiting list for waiver services.1

Basic Care Assistance Program

The Basic Care Assistance program helps qualifying individuals pay a portion of their cost for care while living in a licensed basic care facility. To qualify, a person must live in North Dakota, be 65 or older (or 18 or older and blind or disabled), qualify for North Dakota Medicaid, and have a functional assessment; basic care is for people who are not severely impaired in daily activities, transferring or eating.1 Basic Care Assistance is a facility-based benefit and does not provide direct payment to family caregivers in the home setting.

NFCSP Through NDDHHS Adult and Aging Services

The National Family Caregiver Support Program (Older Americans Act Title III-E) is delivered in North Dakota through NDDHHS Adult and Aging Services. It offers information about local services, help from a trained caregiver coordinator, counseling, support groups and training, respite care for caregivers who provide 24-hour care, and supplemental services toward incontinence supplies and assistive devices such as a shower bench or safety rails. NDDHHS says these services are provided at no cost to qualifying people and are federally funded, and caregivers can contribute toward the cost.1 None of those services is a wage for the caregiver.

To reach these services, call the ND Aging & Disability Resource-LINK toll-free at 1-855-GO2LINK (1-855-462-5465).1 You can also use the Eldercare Locator at eldercare.acl.gov.

The Five Pathways

Pathway 1: HCBS Waiver Family Personal Care

For North Dakotans who qualify for Medicaid and the consolidated HCBS waiver, family personal care is the waiver service built to pay a live-in relative. The steps:

Family personal care is not available to someone eligible for the same services through the Medicaid State Plan or EPSDT, and its recipients cannot also receive adult residential care, adult foster care, transitional living, residential habilitation, community support or companionship services.1

Pathway 2: VA Program of Comprehensive Assistance for Family Caregivers (PCAFC)

The Program of Comprehensive Assistance for Family Caregivers pays a monthly stipend to a designated Primary Family Caregiver of an eligible veteran. The caregiver must be at least 18 and either the veteran's spouse, son, daughter, parent, stepfamily member or extended family member, or someone who lives full time with the veteran (or is willing to if VA designates them), so a spouse can be the paid caregiver.6

Veteran eligibility: VA publishes four conditions, and they are the first screen rather than the decision. The veteran must meet all four:2

• A VA disability rating, individual or combined, of 70 percent or higher.2
• Discharge from the U.S. military, or a date of medical discharge.2
• A need for at least six months of continuous, in-person personal care services.2
• Enrollment in VA health care.2

Meeting those four is necessary, not sufficient. The binding test is 38 CFR 71.20(a), which states seven requirements and requires every one of them. Four of the seven have no counterpart in the four above, and VA assesses them during the application process:2

• Participating in the program is in the veteran's best interest.2
• The personal care services the family caregiver would provide are not simultaneously and regularly provided by or through another individual or entity.2
• The veteran receives care at home, or will do so if VA designates a family caregiver.2
• The veteran receives ongoing care from a primary care team, or will do so if VA designates a family caregiver.2

The no-other-provider condition is the one most likely to surprise a family, because a household already receiving regular personal care through another program or entity can fail PCAFC on that ground alone.2

The monthly stipend starts from the OPM General Schedule grade 4, step 1 annual salary for the veteran's geographic locality, divided by 12. That monthly base is then multiplied by 0.25, 0.625 or 1.00. 38 CFR 71.40(c)(4)(i) sets five rungs using those three multipliers, and which one applies turns first on whether the veteran is in the current program or is a legacy participant or legacy applicant:6,2

• Current program (38 CFR 71.20(a)): 0.625, or 1.00 if VA determines the veteran is unable to self-sustain in the community.
• Legacy participant or legacy applicant (38 CFR 71.20(b) or (c)): the multiplier comes from the sum of the veteran's 2019 clinical ratings, and no self-sustain determination is required on this route. A sum of 21 or higher pays 1.00; 13 to 20 pays 0.625; 1 to 12 pays 0.25.
• Qualifying under both (subparagraph (C)): a veteran who meets the current criteria and the legacy criteria is paid whichever of the two amounts is higher, so an assessment under the current program can never cut a legacy household's stipend.
• The legacy floor (subparagraph (D)): a legacy participant under 71.20(b) is paid not less than what the caregiver was eligible to receive the day before October 1, 2020, so long as the veteran still lives at the address on record. The legacy schedule runs eight years from October 1, 2020 and lapses October 1, 2028.6

The gap between the rungs is the reason to ask which one VA used. A legacy household whose 2019 ratings sum to 21 or higher reaches the full 1.00 rate on that schedule alone, so a family told the self-sustain finding is the only route to the full stipend is underestimating by roughly 1.6 times and may never ask. A legacy household on the 1-to-12 rung, meanwhile, receives 0.25 rather than 0.625 and should budget accordingly.

In the preamble to its 2020 proposed PCAFC rule, VA described the monthly stipend as a nontaxable benefit, and the stipend is paid only once the caregiver is enrolled in direct deposit through the VA customer engagement portal.2 A Primary Family Caregiver may also get access to CHAMPVA health care benefits if they don't already qualify for care or services under another health care plan, plus at least 30 days of respite care per year; Primary and Secondary Family Caregivers can receive mental health counseling and caregiver education and training.6 Because the base rate follows the OPM locality pay area where the veteran lives, check the current GS-4 step 1 rate for that area before budgeting.6

Pathway 3: VA Veteran-Directed Care (VDC)

VA Veteran-Directed Care gives veterans of all ages the chance to receive home and community services in a consumer-directed way. VA developed it with the Administration for Community Living in 2008. It is for veterans who need help with daily activities such as bathing and dressing, or with tasks such as fixing meals, who are isolated, or whose caregiver is experiencing burden. The veteran gets a flexible budget for services, managed by the veteran or the family caregiver, and can hire their own personal care aides, which VA says might include their own family member or neighbor.4

All veterans enrolled in VA health care who meet the clinical need for the service are eligible, but VA says the program is only available in certain locations, and a copay may be charged based on service-connected disability status. To find out whether it is available to your veteran in North Dakota, talk with your VA social worker.4

VA medical centers deliver VDC through a partner agency, such as an area agency on aging or an aging and disability resource center, and the budget is based on the veteran's needs. In ACL's model VDC handbook, which local agencies adapt, a financial management services provider acts as the veteran's payroll agent, issues W-2 forms and pays payroll taxes, and a worker cannot be hired until the spending plan and budget are approved and background checks are complete.7

Pathway 4: VA Aid and Attendance

VA Aid and Attendance is an increased monthly pension for veterans and survivors who already qualify for a VA pension and meet at least one of VA's listed needs, such as needing another person's help with bathing, feeding and dressing.2

2026 Aid and Attendance maximum annual pension rates (effective December 1, 2025 through November 30, 2026), ceilings rather than flat payments:3

• Single veteran: up to $29,093 per year3
• Veteran with one dependent: up to $34,488 per year
• Surviving spouse (no dependents): up to $18,697 per year

VA pays the difference between countable income and the ceiling, so income lowers what's received. The net worth limit is $163,699. VA pension applies a 36-month look-back on asset transfers under 38 CFR 3.276, and the look-back does not reach any date before October 18, 2018.3

The veteran receives the pension. Families can direct those funds toward a family caregiver through a personal arrangement or a personal services contract.

Pathway 5: Private Personal Services Contract

For families outside both VA and North Dakota Medicaid, a family can pay a relative for care privately, usually under a written personal services contract.

North Dakota Medicaid reviews asset transfers over the prior five years (60 months) when deciding long-term care eligibility.1 Under federal law, a transfer for less than fair market value inside the look-back can trigger a penalty period, a span when Medicaid won't pay for nursing facility care or 1915(c) waiver services; it does not end the person's other Medicaid coverage.5 A transfer for which fair market value is received falls outside the penalty by its own terms.8 So if Medicaid might be needed within five years, put the arrangement in writing before care starts, spell out the services, schedule and rate, keep a log of the care given, and have a North Dakota elder-law attorney review it.

How to Choose

Veteran household: If the veteran has a VA disability rating of 70% or higher and needs ongoing in-person personal care, look at PCAFC first, knowing VA's four conditions are a first screen and the regulation adds more. VA has described the stipend as nontaxable, a spouse can be the caregiver, and a Primary Family Caregiver who doesn't already qualify for care under another health care plan may get CHAMPVA health care benefits.2 Layer Aid and Attendance pension on top if the veteran qualifies for both. Ask your VA social worker whether Veteran-Directed Care is available in your location.4

Non-veteran Medicaid household: If the care recipient qualifies for North Dakota Medicaid and meets a nursing facility level of care, family personal care under the HCBS waiver can pay a spouse or listed relative who lives in the same home.1

Private-pay household: A written personal services contract keeps a private arrangement documented. Involve a North Dakota elder-law attorney if the care recipient might apply for North Dakota Medicaid within the next five years, since that is how far back the state reviews asset transfers.1

IRS Notice 2014-7 and Taxes

North Dakota's family personal care pays only legal spouses or family members who live in the same home as the care recipient.1 Under IRS Notice 2014-7, the IRS treats qualified Medicaid waiver payments as difficulty-of-care payments excludable from the caregiver's federal gross income. The notice covers payments to individual care providers under a state Medicaid home and community-based services waiver described in section 1915(c) of the Social Security Act, and the exclusion applies only to payments for care in the provider's own home, where the care recipient lives under their plan of care. The provider's home is where the provider lives and carries on the routines of private life, so the exclusion does not apply to a caregiver who has a separate home where they live.9 Families should verify with a tax professional whether their specific North Dakota arrangement qualifies.

In the preamble to its 2020 proposed PCAFC rule, VA described the monthly stipend as a nontaxable benefit.2

Pay under a private personal services contract is not a waiver payment, so ask a tax professional how it is taxed.

Common Misconceptions

"The HCBS waiver can pay any relative who helps out." Family personal care is limited to a spouse or a parent, grandparent, adult child, adult sibling, adult grandchild, adult niece or adult nephew, and it pays only one who lives in the same home as the care recipient.1

"Medicare pays for ongoing personal care." Original Medicare does not pay family members or friends a wage for personal or custodial care, and it excludes custodial care such as help with bathing or dressing when that is the only care needed. Its home health benefit pays a Medicare-certified agency, never a relative, and requires a homebound patient who needs part-time or intermittent skilled services.10 For ongoing help with daily activities, look to North Dakota Medicaid and the VA programs above.

"A verbal arrangement is enough for Medicaid purposes." North Dakota Medicaid reviews asset transfers over the prior five years,1 and a transfer for less than fair market value in that window can trigger a penalty period.5 A written contract made before care begins, with a record of the care given, is the family's evidence that the payments bought care.

Where to Get Help in North Dakota

Learn More

Find personalized help choosing the right North Dakota paid-caregiver pathway 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.