Georgia Medicaid Self-Directed Services (Section 1915(j)) (2026)

Section 1915(j) of the Social Security Act establishes the Self-Directed Personal Assistance Services State Plan option, a federal Medicaid authority that allows beneficiaries to direct their own personal assistance services, receive an individualized budget, and (in many cases) pay family members as caregivers. Only a small number of states have adopted Section 1915(j) as a standalone State Plan authority. Georgia Medicaid has not adopted Section 1915(j) as a standalone authority but offers limited self-direction within its existing Section 1915(c) NOW and COMP waivers through Participant-Directed Services. This guide explains the federal Section 1915(j) framework, Georgia's existing self-direction options, the policy considerations for and against Section 1915(j) adoption, and what implications Georgia's approach has for families.

By Brevy Care Team · Last verified May 12, 2026

Self-directed services are among the most consequential developments in Medicaid home and community-based services policy over the past three decades. Self-direction allows beneficiaries to control who provides their care, when it is provided, how it is delivered, and (in some authorities) how the individualized budget is allocated. For many families, the ability to hire a daughter, son, sibling, or trusted friend to provide care, with that worker paid through Medicaid, transforms what is otherwise an unsustainable family caregiving situation.

Section 1915(j) of the Social Security Act, added by the Deficit Reduction Act of 2005, established the Self-Directed Personal Assistance Services State Plan option as a permanent federal authority for self-direction. Section 1915(j) built on the Robert Wood Johnson Foundation's Cash and Counseling Demonstration, which had operated in Arkansas, Florida, and New Jersey in the late 1990s and early 2000s. The Cash and Counseling model demonstrated that beneficiaries who self-direct their services tend to report higher satisfaction, better access to care, and similar or better health outcomes compared to traditional agency-delivered care.

This guide is necessary because Georgia families seeking self-direction often do not understand the federal authorities that govern self-direction or how Georgia's specific approach fits within that broader framework. A family might hear that "you can pay family members as caregivers under Medicaid" and assume that option is universally available, when in fact the available pathways depend on which federal authority the state has adopted, which waiver the beneficiary is enrolled in, and which relationship the family member has to the beneficiary. Understanding the Section 1915(j) framework and Georgia's existing self-direction options helps families navigate these complexities and identify the pathways that may be available to them.

The Federal Section 1915(j) Framework

Section 1915(j) Statutory Foundation

Section 1915(j) of the Social Security Act establishes the Self-Directed Personal Assistance Services State Plan option. The statutory text authorizes states to provide, as a State Plan option, self-directed personal assistance services for individuals who would otherwise receive personal care services under State Plan personal care, home and community-based services under Section 1915(c) waivers, or other forms of long-term services and supports.

Section 1915(j) was added to the Social Security Act by the Deficit Reduction Act of 2005. The provision created a permanent State Plan option for self-direction, replacing the need for states to operate self-direction under Section 1115 demonstration authority or as a sub-component of Section 1915(c) waivers.

Key Statutory Features

Section 1915(j) has several distinguishing features compared to other federal HCBS authorities:

1. Self-direction focus. Section 1915(j) is specifically a self-direction authority. The defining feature is that beneficiaries direct their own personal assistance services. This includes hiring workers, firing workers, training workers, scheduling work hours, supervising work, and (in some circumstances) setting wages within state-established parameters.

2. Individualized budget. Section 1915(j) allows states to provide beneficiaries with a cash allowance or individualized budget to purchase personal assistance services and related supports. The individualized budget reflects the dollar amount of services and supports under the beneficiary's direction and is based on an assessment of the beneficiary's needs.

3. Family caregiver payment. Section 1915(j) explicitly permits payment of family members as caregivers, including spouses in some circumstances and other legally responsible relatives. This is one of the most distinctive features of Section 1915(j) and is a key driver of state adoption. State Section 1915(j) programs vary substantially in whether and how they allow spousal payment.

4. State Plan benefit. Section 1915(j) is a State Plan benefit, meaning services must be available statewide (unlike Section 1915(c) waivers, which can be geographically limited). There are no waiting lists, unlike Section 1915(c) waivers which can cap enrollment.

5. Operates alongside existing authorities. Section 1915(j) is not a separate eligibility pathway. Rather, it provides a self-direction overlay for individuals who are already eligible for personal care services or HCBS under another authority. A beneficiary becomes eligible for Section 1915(j) by first being eligible for Section 1905(a)(24) State Plan personal care, a Section 1915(c) waiver service that includes personal care, or another authority that includes personal care.

6. No enhanced FMAP. Unlike Section 1915(k) Community First Choice (which provides an enhanced federal matching rate for CFC services), Section 1915(j) does not provide enhanced federal financial participation. Section 1915(j) services are reimbursed at the standard state FMAP rate.

7. Voluntary participation. Beneficiaries must voluntarily elect self-direction under Section 1915(j). They must also be able to voluntarily disenroll from self-direction and return to agency-delivered services at any time, ensuring self-direction does not become a forced choice that limits access to services.

Cash and Counseling Model

The Cash and Counseling Demonstration was the precursor to Section 1915(j). Operating in Arkansas, Florida, and New Jersey under Section 1115 demonstration authority, the Cash and Counseling model demonstrated the viability of self-direction as a permanent Medicaid option. Cash and Counseling had several core features that became foundational to Section 1915(j):

• Cash allowance. Beneficiaries receive a cash allowance based on an assessment of their needs. The cash allowance is equivalent to what the beneficiary would otherwise receive through agency-delivered services, adjusted for self-direction administrative costs.
• Individualized budget. Beneficiaries develop an individualized budget identifying how they will spend the cash allowance. The budget covers worker wages, related supports (such as assistive technology), and other approved expenditures.
• Support broker or counselor. A support broker or counselor helps beneficiaries develop their service plan, find and hire workers, manage payroll, navigate the self-direction process, and address problems as they arise.
• Financial management services. A financial management services entity processes payroll, withholds taxes, handles employment-related administrative tasks, and ensures workers are paid on time and in compliance with employment law.

Cash and Counseling demonstrated that beneficiaries who self-direct their services have higher satisfaction with their care, better access to services (because they can hire workers who are otherwise unavailable through agencies), and similar or better health outcomes compared to traditional agency-delivered care. The demonstration's success led directly to the enactment of Section 1915(j) as a permanent State Plan option.

Relationship to Other HCBS Authorities

Section 1915(j) operates within a broader federal HCBS authority framework that includes:

• Section 1915(c) HCBS waivers. Many Section 1915(c) waivers include a self-direction option (sometimes called "participant-directed services" or "consumer-directed services"). Section 1915(c) waivers can be geographically limited, can have waiting lists, and require beneficiaries to meet institutional level of care criteria. Georgia's NOW and COMP waivers are examples of Section 1915(c) waivers with self-direction options.
• Section 1915(i) HCBS State Plan option. Section 1915(i) allows states to offer HCBS as a State Plan benefit for individuals who do not meet institutional level of care. Section 1915(i) can include self-direction but is not specifically a self-direction authority. Georgia has not adopted Section 1915(i).
• Section 1915(k) Community First Choice. Section 1915(k) requires states to offer self-direction as part of the State Plan benefit. Section 1915(k) provides an enhanced federal matching rate for CFC services and requires statewide availability without waiting lists. Georgia has not adopted Section 1915(k).
• Section 1905(a)(24) State Plan personal care. State Plan personal care services can include a self-direction option, but Section 1915(j) provides a more comprehensive self-direction framework with required infrastructure (financial management services, support brokers, etc.).

A state can have all of these authorities operating simultaneously, with beneficiaries potentially eligible for self-direction under multiple authorities depending on their needs and circumstances.

The CMS Regulatory Framework

42 CFR Part 441 Subpart J: Section 1915(j) Regulations

CMS regulations governing Section 1915(j) are codified at 42 CFR Part 441 Subpart J. The regulations specify requirements for state Section 1915(j) programs across a structured set of topics:

Statutory basis and scope. Establishes the statutory foundation for Section 1915(j) regulations and defines the scope of services that may be provided.

Needs-based eligibility. Beneficiaries must be eligible for personal care services or HCBS under another authority and must voluntarily elect self-direction. A needs-based assessment determines the level of services required.

Service plan. Each beneficiary has a service plan developed through a person-centered planning process. The service plan identifies the services the beneficiary will receive, who will provide them, when they will be provided, and how the beneficiary will direct them.

Individualized budget. Each beneficiary has an individualized budget identifying the dollar amount of services and supports under the beneficiary's direction. The individualized budget reflects the cost of services the beneficiary would otherwise receive through agency-delivered care.

Quality assurance. States must have quality assurance systems including reporting of critical incidents (such as injury, abuse, or service interruption). States must monitor beneficiary outcomes, address concerns promptly, and report quality metrics to CMS.

Financial management services. States must provide financial management services to handle payroll, tax withholding, and employment-related administrative tasks. Financial management services may be provided directly by the state, through a contract with a third-party entity, or through a combination.

Support broker or counselor. States must provide support brokers or counselors to help beneficiaries develop and implement their service plan. Support brokers help beneficiaries find and hire workers, navigate problems, and access additional resources as needed.

Voluntary disenrollment. Beneficiaries must be able to voluntarily disenroll from self-direction and return to agency-delivered services at any time. This protects beneficiaries who find self-direction unworkable for their circumstances.

Cash and counseling model. Regulations govern the cash and counseling model of self-direction, including how cash allowances are calculated, how individualized budgets are developed, and how funds are managed.

Backup plan. Each beneficiary must have a backup plan for situations where the primary worker is unavailable. The backup plan addresses how the beneficiary will receive needed services in case of worker absence, illness, or emergency.

Risk management. States must have risk management protocols to address health and safety risks, helping ensure that self-direction does not compromise beneficiary health or safety. Refer to 42 CFR Part 441 Subpart J for the current operative text of each requirement.

CMS Guidance Documents

CMS has issued substantial guidance on Section 1915(j) implementation:

• CMS State Medicaid Director Letter. Initial guidance on Section 1915(j) accompanying the Final Rule.
• CMS Technical Assistance Tool for Section 1915(j). Implementation guidance for states considering Section 1915(j) adoption.
• CMS Self-Direction Toolkit. Comprehensive resources for states implementing self-direction across multiple authorities (1915(c), 1915(i), 1915(j), 1915(k), and 1905(a)(24)).

Person-Centered Planning Requirement

Like other HCBS authorities, Section 1915(j) requires person-centered planning. The person-centered planning process is led by the beneficiary, identifies the beneficiary's goals and preferences, includes the people the beneficiary chooses to include in the planning process, and results in a service plan that reflects the beneficiary's choices. Person-centered planning is foundational to self-direction because it ensures the services and supports are tailored to the beneficiary's specific needs and preferences rather than being delivered in standardized packages.

HCBS Settings Rule Application

42 CFR 441.530 (the HCBS settings rule) applies to all HCBS authorities including Section 1915(j). The HCBS settings rule requires that services be delivered in settings that are integrated into the broader community, support full access to the community, allow individuals to seek employment and engage in community life, and ensure individual rights of privacy, dignity, and respect.

For Section 1915(j) self-directed services, the settings rule means that services should be delivered in the beneficiary's home or other community settings, with the beneficiary having control over their own schedule, who provides their care, and how they engage in the community. The HCBS settings rule applies to all HCBS settings regardless of whether services are agency-delivered or self-directed.

Conflict of Interest Standards

Section 1915(j) regulations require that the entity providing case management or support broker services be separate from the entity providing direct services. This separation is intended to prevent conflict of interest between case management and service provision. Support brokers must be independent of direct service providers to ensure they advocate for the beneficiary rather than for service utilization.

State Adoption of Section 1915(j)

Current State Adoption

Only a small number of states have adopted Section 1915(j) as a standalone State Plan authority; the precise count varies based on methodology, active program status, and whether states are counted that have Section 1915(j) programs combined with other authorities. States with substantial Section 1915(j) programs have historically included:

• Alabama. Section 1915(j) Personal Choices program. Allows self-direction including limited family caregiver payment.
• Arkansas. Section 1915(j) IndependentChoices program. Direct descendant of the original Cash and Counseling Demonstration in Arkansas.
• California. Section 1915(j) self-directed services (operates alongside CFC).
• Florida. Section 1915(j) Consumer Directed Care Plus. Descendant of the original Cash and Counseling Demonstration in Florida.
• Illinois. Section 1915(j) Home Services Program self-direction.
• Iowa. Section 1915(j) Consumer Choices Option.
• New Jersey. Section 1915(j) Personal Preference Program. Descendant of the original Cash and Counseling Demonstration in New Jersey.
• Oregon. Section 1915(j) self-direction (limited, operating alongside CFC).
• Pennsylvania. Section 1915(j) Services My Way.
• Texas. Section 1915(j) self-direction (operating alongside CFC).
• Wisconsin. Section 1915(j) IRIS (Include, Respect, I Self-Direct), a large Section 1915(j) program serving individuals across multiple disability populations.

For the current operative roster of states with active Section 1915(j) programs, consult the CMS Self-Directed Services page. Many additional states offer self-direction through Section 1915(c) waivers, Section 1915(i) State Plan HCBS, Section 1915(k) Community First Choice, or Section 1905(a)(24) State Plan personal care without adopting Section 1915(j) as a standalone authority.

Why States Adopt Section 1915(j)

States adopt Section 1915(j) for several reasons:

1. Beneficiary satisfaction. Self-directed care consistently shows higher beneficiary satisfaction compared to agency-delivered care. Cash and Counseling Demonstration data and subsequent research have established self-direction as a high-value option for many beneficiaries.

2. Family caregiver payment. Section 1915(j) allows payment of family members as caregivers. This addresses a significant unmet need in many state Medicaid programs and provides families with a sustainable model for caregiving.

3. Worker recruitment. Self-direction can help address direct care worker shortages by expanding the pool of potential workers. Family members, friends, neighbors, and others who would not work for an agency may be willing to provide care through self-direction.

4. Cost-effectiveness. Self-directed care can be cost-comparable to or less expensive than agency-delivered care in many contexts. While Section 1915(j) requires substantial infrastructure (financial management services, support brokers), the per-beneficiary cost is often similar to or lower than agency-delivered care.

5. Statewide availability. Section 1915(j) requires statewide availability and prohibits waiting lists. This expands access to self-direction compared to waiver-based self-direction, which can be geographically limited or capped.

6. Person-centered planning alignment. Self-direction aligns with person-centered planning principles that have become foundational to HCBS policy. Self-direction operationalizes person-centered planning by giving beneficiaries actual control over their services rather than just input into service planning.

7. Population flexibility. Section 1915(j) can serve diverse populations including older adults, individuals with physical disabilities, individuals with developmental disabilities, individuals with mental health conditions, and individuals with brain injury. This flexibility allows states to use Section 1915(j) as a comprehensive self-direction infrastructure across multiple populations.

Why States Do Not Adopt Section 1915(j)

States may decline to adopt Section 1915(j) for several reasons:

1. No enhanced FMAP. Unlike Section 1915(k) Community First Choice (which provides an enhanced federal matching rate), Section 1915(j) does not provide enhanced federal financial participation. This reduces the financial incentive to adopt Section 1915(j) as a standalone authority when self-direction is already available through other authorities.

2. State share of expanded services. Statewide availability and no waiting lists mean the state cannot cap enrollment in Section 1915(j). If demand exceeds projections, the state share of expanded services can create fiscal pressure.

3. Implementation complexity. Section 1915(j) requires substantial implementation infrastructure including financial management services contracts, support broker networks, individualized budget methodologies, person-centered planning systems, backup plan protocols, risk management frameworks, and quality assurance systems. Building this infrastructure requires substantial state investment.

4. Existing waiver infrastructure. States that already offer self-direction through Section 1915(c) waivers may not see additional benefit from adopting Section 1915(j) as a standalone authority. If a state's existing waivers cover the relevant populations and include self-direction, Section 1915(j) may be redundant.

5. Quality assurance burden. Section 1915(j) requires robust quality assurance systems including critical incident reporting, beneficiary outcome monitoring, and quality metrics reporting to CMS. This administrative burden is substantial.

6. Family caregiver payment concerns. Some states have policy concerns about paying family members (particularly spouses) as caregivers. Concerns include fraud risk, family dynamics, and the principle that family caregiving is a natural responsibility that should not be commercialized.

7. Stakeholder dynamics. Existing agency providers may oppose Section 1915(j) adoption because self-direction can divert beneficiaries from agency-delivered services to family caregivers and individual workers. Union and worker representation concerns may also arise.

8. Legislative or executive priorities. State Medicaid policy priorities may be focused on other initiatives (managed care implementation, eligibility expansion, waiver waiting list reduction, etc.) rather than self-direction.

Georgia's HCBS and Self-Direction Framework

Georgia's HCBS Authority Structure

Georgia operates HCBS through five Section 1915(c) waivers, each with different administering agencies, target populations, eligibility criteria, and self-direction options:

1. CCSP (Community Care Services Program). Administered by Georgia DCH. Serves older adults (typically 65+) and adults with physical disabilities who meet nursing facility level of care. CCSP has a limited self-direction option for personal care services, allowing participants to direct their personal care worker. CCSP also includes Structured Family Caregiving (SFC), which provides a stipend to family caregivers who live with the care recipient.

2. SOURCE (Service Options Using Resources in a Community Environment). Administered by DCH. Serves dually eligible Medicare/Medicaid beneficiaries 65+ who meet nursing facility level of care. SOURCE does not include a self-direction option. SOURCE participants receive agency-delivered services through case management arrangements. SOURCE includes Structured Family Caregiving similar to CCSP.

3. ICWP (Independent Care Waiver Program). Administered by DCH. Serves adults 21-64 with physical disabilities who meet hospital or nursing facility level of care. ICWP does not include a self-direction option. ICWP participants receive agency-delivered services.

4. NOW (New Options Waiver). Administered by DBHDD. Serves individuals with intellectual/developmental disabilities who meet ICF/IID level of care. NOW includes a robust Participant-Directed Services option allowing self-direction across multiple service categories.

5. COMP (Comprehensive Supports Waiver Program). Administered by DBHDD. Serves individuals with intellectual/developmental disabilities with more complex needs requiring more intensive supports. COMP includes a robust Participant-Directed Services option similar to NOW.

Georgia State Plan Personal Care

Georgia's Medicaid State Plan includes a limited personal care benefit under Section 1905(a)(24). State Plan personal care in Georgia is narrow in scope and does not include comprehensive self-direction. Most Georgia Medicaid beneficiaries who need personal care services receive them through one of the Section 1915(c) waivers or through Medicare (for dual eligibles).

Participant-Directed Services in NOW and COMP

Georgia's NOW and COMP waivers (administered by DBHDD) include a Participant-Directed Services option that provides the most developed self-direction in Georgia Medicaid. Key features of NOW/COMP Participant-Directed Services:

• Eligible services. Community Living Support (CLS), Community Access (CA), Respite, and certain other personal assistance services may be participant-directed. Not all NOW/COMP services are eligible for participant direction.

• Employer of record. The participant (or their authorized representative) serves as the employer of record for their direct support professionals. The participant has authority over hiring, firing, training, scheduling, and supervising workers.

• Financial management services. DBHDD contracts with financial management services entities to handle payroll, tax withholding, workers' compensation, unemployment insurance, and employment-related administrative tasks. The participant does not handle these tasks directly.

• Support coordinator. Each participant has a support coordinator who helps develop and implement the individual service plan. Support coordinators help participants understand their options, develop their service plan, and navigate the participant-direction process.

• Family caregiver payment. Family members may serve as paid direct support professionals under Participant-Directed Services, subject to certain restrictions. Legally responsible relatives (parents of minor children, spouses) generally cannot be paid. Adult siblings, adult children of the participant, and other non-legally-responsible relatives generally can be paid if they meet the qualifications.

• Individual budget authority. Participants have authority over how their individual budget is allocated among eligible services within DBHDD parameters. Participants can choose, within limits, how many hours of each service type to receive.

• Backup plan. Participants must have a backup plan addressing how they will receive needed services if their primary worker is unavailable.

CCSP Self-Direction Option

CCSP has a limited self-direction option for personal care services. Under CCSP self-direction:

• Personal care worker direction. Participants can direct their personal care worker, including selecting, scheduling, supervising, and (in some cases) hiring or firing the worker.
• Agency intermediary. A home care agency typically serves as the intermediary for payroll and employment-related tasks.
• Limited scope. CCSP self-direction is limited to personal care services and does not extend to other CCSP services.
• Family caregiver payment. Family members can be hired as personal care workers under CCSP self-direction, subject to background checks, training requirements, and restrictions on legally responsible relatives.

CCSP self-direction is less developed than NOW/COMP Participant-Directed Services. The self-direction infrastructure (financial management services, dedicated support brokers, individualized budget authority) is more limited.

Structured Family Caregiving Under CCSP/SOURCE

Structured Family Caregiving (SFC) is a distinct DCH program available under CCSP and SOURCE that provides a stipend to family caregivers who live with the care recipient and provide substantial daily care. SFC is not technically a self-direction program under Section 1915(j), but it provides one of the most accessible pathways in Georgia for family caregiver payment.

SFC key features:

• Live-in requirement. The family caregiver must live with the care recipient.
• Stipend payment. SFC provides a monthly stipend to the family caregiver rather than an hourly wage. Stipend amounts vary based on the care recipient's needs and acuity level.
• Tax-favored treatment. SFC stipends are commonly treated as difficulty-of-care payments under IRS guidance for foster-care-style payments made to individuals living with the care recipient, which may make them excludable from federal income tax in many circumstances. Families should consult a tax professional and the current IRS guidance for specific treatment.
• Agency intermediary. A home care agency typically serves as the intermediary, providing case management, training, and administrative support.
• Family relationship eligibility. Spouses generally cannot serve as SFC caregivers (because SFC is intended to supplement rather than replace family caregiving expected of spouses). Adult children, siblings, and other non-spousal family relationships are typically eligible.

Why Georgia Has Not Adopted Section 1915(j) as a Standalone Authority

Georgia has not adopted Section 1915(j) as a standalone State Plan authority for several reasons:

1. Existing self-direction infrastructure. Georgia already offers self-direction through NOW/COMP Participant-Directed Services (for IDD populations) and CCSP limited self-direction (for older adults and adults with physical disabilities). This existing infrastructure reduces the perceived need for a standalone Section 1915(j) authority.

2. State share of expanded services. Adopting Section 1915(j) as a standalone State Plan authority would require statewide availability and prohibit waiting lists. This would mean the state cannot cap enrollment in Section 1915(j), increasing fiscal risk if demand exceeds projections.

3. Family caregiver payment concerns. Georgia has historically been cautious about expanding family caregiver payment, particularly to spouses and legally responsible relatives. Section 1915(j) allows broader family caregiver payment than Georgia's existing programs, which has been a policy concern.

4. Implementation complexity. Section 1915(j) requires substantial implementation infrastructure (financial management services contracts, support broker networks, individualized budget methodologies, backup plan protocols, risk management frameworks, quality assurance systems). Building this infrastructure requires substantial state investment.

5. No enhanced FMAP. Without enhanced FMAP, there is no specific financial incentive to adopt Section 1915(j) over expanding self-direction within existing waivers. The state would bear its standard share of Section 1915(j) costs.

6. Stakeholder priorities. Georgia's Medicaid policy priorities have been focused on other initiatives including Pathways to Coverage (Georgia's narrowly-targeted Section 1115 demonstration for the expansion population), waiver waiting list reduction, behavioral health investment, and managed care optimization.

7. No legislative direction. The Georgia General Assembly has not directed DCH or DBHDD to adopt Section 1915(j). Section 1915(j) adoption would require state plan amendment approval and implementation funding.

8. CMS Region IV oversight. CMS Region IV (which oversees Georgia and other southeastern states) has not specifically encouraged Section 1915(j) adoption. Region IV has been focused on other priorities including waiver renewals and managed care implementation.

Implications for Georgia Families

Self-Direction Pathways Available in Georgia Today

Georgia families seeking self-direction can access it through:

1. NOW Participant-Directed Services. Families of individuals with intellectual/developmental disabilities on NOW can elect Participant-Directed Services for eligible services (Community Living Support, Community Access, Respite, etc.). Subject to NOW eligibility (ICF/IID level of care) and waiver enrollment (waiting list applies; waits can be substantial for some service slots).

2. COMP Participant-Directed Services. Families of individuals with intellectual/developmental disabilities on COMP can elect Participant-Directed Services for eligible services. Subject to COMP eligibility (ICF/IID level of care with more intensive needs) and waiver enrollment (waiting list applies).

3. CCSP limited self-direction. CCSP participants can direct their personal care worker (limited self-direction). Subject to CCSP eligibility (nursing facility level of care) and waiver enrollment (waiting list may apply depending on service type).

4. Structured Family Caregiving under CCSP/SOURCE. Family caregivers living with the care recipient under CCSP or SOURCE can receive a stipend through Structured Family Caregiving. This is the most accessible pathway in Georgia for family caregiver payment.

Where Self-Direction Is Not Available in Georgia

1. SOURCE. SOURCE does not include a self-direction option for personal care or other services. SOURCE participants receive agency-delivered services through case management arrangements.

2. ICWP. ICWP does not include a self-direction option. ICWP participants (adults 21-64 with physical disabilities) receive agency-delivered services.

3. State Plan personal care. Georgia's State Plan personal care benefit is limited in scope and does not include comprehensive self-direction.

4. Individuals not eligible for 1915(c) waivers. Individuals who do not meet institutional level of care criteria cannot access self-direction in Georgia Medicaid. Because Georgia has not adopted Section 1915(i) (which would allow sub-institutional eligibility) or Section 1915(k) Community First Choice, and because Section 1915(j) is not available as a standalone authority, sub-institutional self-direction is not available.

Family Caregiver Payment Pathways in Georgia

Georgia families seeking to be paid as caregivers can explore:

1. NOW/COMP Participant-Directed Services. Family members other than legally responsible relatives (so adult siblings, adult children of participants, etc.) can be paid as direct support professionals if they meet qualifications. Subject to NOW/COMP eligibility and enrollment.

2. CCSP self-direction. Family members can be hired as personal care workers under CCSP self-direction, subject to background checks, training requirements, and restrictions on legally responsible relatives.

3. Structured Family Caregiving (SFC) under CCSP/SOURCE. Family caregivers living with the care recipient can receive a stipend. This is one of the most accessible family caregiver payment options in Georgia.

4. Veterans Affairs programs. VA Aid and Attendance benefits, VA Veteran Directed Care (which is essentially VA's version of self-direction), VA HCBS programs, and other VA programs may provide family caregiver payment for eligible veterans.

5. Private pay or long-term care insurance. Outside of Medicaid and VA, family caregivers can be compensated through private pay arrangements or long-term care insurance benefits if the insurance policy allows family caregiver payment.

Limitations of Georgia's Current Approach

Georgia's current approach to self-direction has several limitations:

1. Limited population coverage. Self-direction is most developed for individuals with IDD (NOW/COMP Participant-Directed Services). Older adults and adults with physical disabilities have more limited self-direction options through CCSP or no self-direction (SOURCE, ICWP).

2. Institutional level of care requirement. All self-direction in Georgia operates within 1915(c) waivers, which require institutional level of care. Individuals with sub-institutional needs cannot access self-direction in Georgia Medicaid.

3. Waiting lists. NOW/COMP have substantial waiting lists, meaning many families who would benefit from Participant-Directed Services cannot access it until they reach the top of the list.

4. Spousal payment restrictions. Georgia's existing programs generally do not allow spousal payment. Section 1915(j) (as implemented in some states) allows spousal payment in defined circumstances.

5. Limited support broker infrastructure. Georgia's self-direction does not have the dedicated support broker infrastructure that Section 1915(j) requires. Support coordinators in NOW/COMP serve multiple functions including but not limited to self-direction support.

6. Limited financial management services choice. Beneficiaries have limited choice among financial management services entities. Some states with mature Section 1915(j) programs offer multiple FMS options to allow beneficiaries to choose the FMS that best meets their needs.

7. Variable program features. Self-direction features vary across NOW, COMP, and CCSP, creating complexity and potential confusion for families navigating multiple programs or transitioning between programs.

Worked Examples

These worked examples illustrate how the Section 1915(j) framework would apply in Georgia and how Georgia's existing self-direction options compare. All names and circumstances are illustrative.

Sarah 35 Atlanta: daughter providing care under self-direction

Sarah's mother Patricia (72) has multiple chronic conditions including diabetes, heart failure, and early-stage Alzheimer's disease. Patricia needs help with bathing, dressing, meal preparation, medication management, and supervision throughout the day. Patricia is enrolled in CCSP and receives personal care services. Sarah works part-time as a teacher's aide and wants to be paid to provide care for her mother, allowing her to leave her part-time job and provide full-time care.

Sarah's options under Georgia's current framework:

1. CCSP self-direction. Sarah may be able to be hired as Patricia's personal care worker under CCSP's limited self-direction. Sarah would need to meet CCSP personal care worker qualifications including background check, training requirements, and being authorized through the CCSP self-direction process. Hours would be based on Patricia's assessed needs (typically not full-time hours under CCSP).

2. Structured Family Caregiving (SFC) under CCSP. If Sarah moves in with Patricia and provides 24-hour care, Sarah may be eligible for SFC stipend. SFC provides a monthly stipend rather than hourly wage. The stipend amount depends on Patricia's acuity level. SFC is administered through a home care agency intermediary.

3. NOW/COMP. Not applicable because Patricia does not have intellectual/developmental disability.

4. VA programs. Not applicable unless Patricia is a veteran with eligible service-connected conditions.

If Georgia had adopted Section 1915(j) as a standalone authority, Sarah would have:

• A clearer pathway to be paid for care across more service types.
• An individualized budget allowing Sarah to plan her work hours.
• A dedicated support broker helping navigate the self-direction process.
• Potentially more flexible service definitions.
• Statewide availability without waiting list dependency.

Recommendation for Sarah: explore Structured Family Caregiving (most accessible if she can live with Patricia) and CCSP self-direction (if she cannot live with Patricia or prefers hourly payment). Consult an elder law attorney or DAS Aging and Disability Resource Connection for guidance on the specific tradeoffs.

Margaret 78 Savannah: CCSP self-direction

Margaret has age-related functional decline and needs help with bathing, dressing, meal preparation, and light housekeeping. She lives alone in her home and wants to remain there. Margaret is enrolled in CCSP and receives personal care services through a home care agency. Margaret has had several conflicts with the agency-assigned personal care worker (scheduling problems, communication issues) and wants more control over her care.

Margaret's options under CCSP self-direction:

1. Hire her own personal care worker. Margaret can recruit, interview, hire, and supervise her own personal care worker. The worker must meet CCSP qualifications including background check and training requirements.
2. Set the worker's schedule. Margaret can determine when the worker comes, what tasks the worker performs, and how the work is performed.
3. Train and supervise. Margaret provides task-specific training and supervises the worker's performance.
4. Terminate if needed. If the worker does not meet Margaret's needs, Margaret can terminate the relationship and hire a different worker.

Limitations of CCSP self-direction:

1. Limited individualized budget authority. Margaret does not have full individualized budget authority. Her service hours are determined by CCSP assessment.
2. Cannot hire spouse or legally responsible relatives. This is moot for Margaret (she is widowed) but would be relevant for other CCSP participants.
3. Less developed self-direction infrastructure. CCSP's self-direction is less developed than NOW/COMP Participant-Directed Services, with more limited support broker infrastructure.

If Georgia had adopted Section 1915(j), Margaret could have:

• An individualized budget reflecting her specific needs and preferences.
• More flexibility in how her budget is allocated among different service types.
• A dedicated support broker helping her navigate self-direction.
• Statewide availability without dependence on CCSP enrollment.

Recommendation for Margaret: pursue CCSP self-direction. Contact DCH's CCSP program for information on the self-direction process and available financial management services support.

David 25 Augusta: NOW Participant-Directed for IDD employment supports

David has Down syndrome and lives with his parents Robert and Linda. David is enrolled in NOW and receives Community Access services to support his community participation and employment goals. David's family wants him to direct his own community access and employment supports, including hiring his older sister Maria (age 32) as his direct support professional.

David's options under NOW Participant-Directed Services:

1. Elect Participant-Directed Services. David, with his parents serving as authorized representatives (because David has cognitive limitations affecting self-direction capacity), can elect Participant-Directed Services for eligible NOW services including Community Access.

2. Hire Maria as direct support professional. Maria can be hired as David's direct support professional because she is not a legally responsible relative (she is David's adult sibling, not his parent or spouse). Maria must meet qualifications including background check, training, and authorized through DBHDD's self-direction process.

3. Robert and Linda cannot be paid. David's parents Robert and Linda cannot be paid as David's direct support professionals because they are legally responsible relatives serving as authorized representatives. This is a long-standing restriction in Georgia's Participant-Directed Services and most state self-direction programs.

4. DBHDD financial management services. DBHDD's contracted FMS entity handles Maria's payroll, tax withholding, workers' compensation, and employment-related administrative tasks.

5. Support coordinator assistance. David's support coordinator helps David and his family develop and implement the individual service plan, including the participant-direction component.

Recommendation for David's family: pursue Participant-Directed Services. Contact David's NOW support coordinator to initiate the participant-direction process. Maria should begin the qualification process (background check, training) before participant-direction is fully implemented.

Henry 50 Macon: exploring whether spouse can be paid

Henry has multiple sclerosis with progressive disability. He needs help with bathing, dressing, transferring, meal preparation, medication management, and supervision. Henry's wife Patricia (48) provides full-time care, having left her career to do so. Henry is enrolled in ICWP. Patricia wants to be compensated for the care she provides.

Henry's options under Georgia's current framework:

1. ICWP. ICWP does not include self-direction, so Henry cannot direct his services or hire Patricia as a paid worker. ICWP participants receive agency-delivered services.

2. CCSP. Henry is under 65 and has physical disability rather than age-related need, so CCSP may not be the optimal fit. However, if Henry meets CCSP eligibility, he could explore CCSP self-direction. Even under CCSP self-direction, Patricia generally cannot be paid because she is Henry's spouse (legally responsible relative).

3. Structured Family Caregiving. SFC under CCSP/SOURCE generally does not allow spouses to serve as SFC caregivers, because SFC is intended to supplement rather than replace family caregiving expected of spouses.

4. VA programs. If Henry is a veteran with service-connected MS or other VA-eligible conditions, he could explore VA Aid and Attendance, VA Veteran Directed Care, or other VA programs. Some VA programs allow spousal payment.

5. Private pay or long-term care insurance. Henry and Patricia could pursue private pay arrangements or, if Henry has long-term care insurance that allows family caregiver payment, use insurance benefits to compensate Patricia.

If Georgia had adopted Section 1915(j) and structured the program to allow spousal payment (as some states have done), Henry might have a Medicaid pathway to pay Patricia. Some states' Section 1915(j) programs allow spousal payment in defined circumstances (e.g., when the spouse would otherwise lose income, when the disability is severe, etc.).

Recommendation for Henry: explore VA programs if Henry is a veteran. Otherwise, the Medicaid pathways for spousal payment in Georgia are very limited. Consult an elder law attorney for comprehensive analysis of Henry's specific situation.

Linda 42 Athens: self-directed budget for personal assistance

Linda has a traumatic brain injury (TBI) from a car accident at age 35. She has cognitive and physical disabilities affecting her ability to live independently. Linda needs personal assistance, cognitive support, transportation, and assistive technology. Linda is enrolled in ICWP.

Linda's options under Georgia's current framework:

1. ICWP services. ICWP provides agency-delivered services including personal care, attendant care, case management, and certain other services. Linda does not have individualized budget authority. Service hours are determined by ICWP assessment.

2. Limited flexibility. Linda's flexibility to use her services for non-traditional supports (assistive technology beyond standard ICWP coverage, specific transportation arrangements, etc.) is limited.

3. No self-direction. ICWP does not include self-direction, so Linda cannot direct her own services or hire her own workers.

If Georgia had adopted Section 1915(j), Linda could have:

• An individualized budget based on her assessed needs.
• Flexibility to purchase non-traditional supports within Section 1915(j) parameters.
• Self-direction authority over her personal assistance services.
• A dedicated support broker helping her navigate self-direction.

Recommendation for Linda: work with her ICWP case manager to maximize her ICWP services. If her brain injury rehabilitation needs cannot be met through ICWP, explore other resources including the Brain and Spinal Injury Trust Fund Commission (BSITF), vocational rehabilitation services, and TBI-focused community-based organizations.

Robert 65 Columbus: support broker for navigating self-direction

Robert is newly enrolled in CCSP. He has multiple chronic conditions and needs help with personal care and other ADLs. Robert wants to direct his own care but is overwhelmed by the administrative tasks involved (hiring workers, managing payroll, complying with employment law, handling scheduling, supervising work). Robert wants a dedicated person to help him navigate self-direction.

Robert's options under Georgia's current framework:

1. CCSP self-direction with case manager support. Robert can pursue CCSP self-direction with his CCSP case manager providing general support. The case manager helps coordinate his services and addresses problems as they arise. However, the case manager is not a dedicated support broker focused specifically on self-direction.

2. Home care agency intermediary. Robert can use a home care agency as an intermediary for payroll and HR support. The agency handles payroll, tax withholding, and employment-related administrative tasks. Robert retains direction authority over scheduling, supervision, and worker selection.

3. Family member or friend as informal support. Robert may have a family member or friend who can help him with administrative tasks. This is informal support rather than a dedicated support broker.

If Georgia had adopted Section 1915(j), Robert could have:

• A dedicated support broker / counselor whose role is specifically to help him navigate self-direction.
• A financial management services entity that handles all payroll, taxes, and employment-related administrative tasks.
• A more comprehensive self-direction framework with backup plans, risk management, and quality assurance built in.
• Multiple FMS options to choose from based on his specific needs.

Recommendation for Robert: pursue CCSP self-direction with home care agency intermediary for payroll and HR support. Engage with DAS Aging and Disability Resource Connection for information on additional resources. If self-direction becomes overwhelming, Robert can return to agency-delivered care at any time.

Frequently Asked Questions

Final Notes for Georgia Families

Section 1915(j) is one of four federal HCBS authorities (along with Section 1915(c) waivers, Section 1915(i) HCBS State Plan option, and Section 1915(k) Community First Choice), and it provides the most comprehensive federal framework for self-directed personal assistance services. Self-direction allows beneficiaries to control who provides their care, when it is provided, how it is delivered, and how their individualized budget is allocated. For many Georgia families, the ability to hire a daughter, son, sibling, or trusted friend as a paid caregiver transforms what is otherwise an unsustainable caregiving situation.

Georgia has not adopted Section 1915(j) as a standalone State Plan authority. Georgia offers self-direction through Section 1915(c) waivers, most notably NOW and COMP Participant-Directed Services (the most developed self-direction in Georgia, available to individuals with intellectual/developmental disabilities) and CCSP limited self-direction (available to older adults and adults with physical disabilities, with less comprehensive self-direction infrastructure). Georgia also offers Structured Family Caregiving under CCSP and SOURCE, which provides a stipend to family caregivers who live with the care recipient.

If you are a Georgia family seeking self-direction or family caregiver payment, your pathways depend on your specific situation. If your loved one has intellectual/developmental disability, NOW or COMP Participant-Directed Services is typically the most comprehensive option. If your loved one is an older adult or adult with physical disabilities, CCSP self-direction or Structured Family Caregiving may be available. If your loved one is a veteran, VA programs may provide additional options. If your loved one does not meet institutional level of care, Georgia Medicaid self-direction options are limited because Georgia has not adopted Section 1915(i), Section 1915(j) standalone, or Section 1915(k).

Brevy is a digital ally helping Georgia families understand the federal Section 1915(j) framework and Georgia's existing self-direction options. Brevy publishes guides at brevy.com to help families navigate Medicaid, Medicare, VA benefits, caregiving, and senior care. Brevy does not provide legal or financial advice. For specific guidance on your situation, including self-direction options, family caregiver payment pathways, Medicaid eligibility, and long-term care planning, consult Georgia Department of Community Health, Department of Behavioral Health and Developmental Disabilities, Division of Aging Services, elder law attorneys, and other qualified professionals.

Find personalized help navigating Georgia at brevy.com.