How Does Self-Direction Differ by State? Programs, Eligibility, and Questions to Ask

In this guide, we’ll explain why self-direction differs by state, what changes from program to program, and what to ask so you can understand how it works where you live. If you’re brand new to the topic, you may want to start with our overview, Understanding Self-Directed Care: What It Is and How It Works.

Most self-direction programs in the United States are funded by Medicaid. Medicaid is paid for jointly by the federal government and each state, and each state runs its own Medicaid program within federal guidelines.

That shared structure is the main reason self-direction varies so much. The federal government sets the framework, and each state decides how to design its programs, who they serve, and how they operate within that framework.

This is different from Medicare, which is a federal program with rules that are consistent across the country. Medicaid, and the self-direction programs it funds, can look very different depending on where you live.

Even with all that variety, self-direction programs share some common ground. According to the Centers for Medicare & Medicaid Services (CMS), self-directed services generally include:

• A person-centered planning process built around your needs, preferences, and goals
• An individualized budget or service plan that outlines the support you are approved to receive
• Access to Financial Management Services (FMS) to help handle the payroll and financial side of the program
• Support from someone who can help you understand and manage your responsibilities

At the heart of every program is the same idea: you or a loved one have more say in who provides care, and how and when that care is delivered.

Federal law gives states several different ways to offer self-direction. States can use some, all, or none of them. The most common include:

• Section 1915(c) Home and Community-Based Services (HCBS) waivers: Allow states to provide long-term care at home or in the community instead of in an institution
• Section 1915(i) HCBS State Plan Option: Lets states offer home and community-based services as part of their regular Medicaid plan
• Section 1915(j) Self-Directed Personal Assistance Services: A state plan option built specifically around self-directing personal assistance
• Section 1915(k) Community First Choice: A state plan option for home and community-based attendant services and supports
• Section 1115 demonstrations: Allow states to test new approaches to delivering Medicaid services

You do not need to memorize these. What matters is that the authority a state uses shapes how the program works, including who can enroll and whether there is a waiting list. For a closer look at how waivers work, see our guide to Medicaid waivers.

Some states also offer self-directed programs funded with state dollars instead of Medicaid. For example, Pennsylvania’s Act 150 Program is state funded and serves some adults with physical disabilities who do not financially qualify for Medicaid. You can learn more by reading our blog: Understanding Self-Directed Care in Pennsylvania.

Explore Programs by State

Here are the most common differences you will run into as you research self-directed care programs in your state.

Depending on where you live, self-direction may be called consumer direction, participant direction, consumer-directed care, self-determination, or something else entirely. Here are a few examples:

• New York’s Consumer Directed Personal Assistance Program (CDPAP)
• Colorado’s Consumer-Directed Attendant Support Services (CDASS)
• California’s Self-Determination Program (SDP)
• Arkansas’s IndependentChoices

Many states offer more than one self-directed program, each serving a different group. If you are not finding what you expect, try searching your state Medicaid agency’s website for “self-direction,” “consumer directed,” or “participant directed.”

Every self-direction program has its own eligibility rules. Most require that you are enrolled in Medicaid, but Medicaid’s financial eligibility rules also vary by state.

Beyond Medicaid, programs are often designed for specific groups. Depending on the program, it may serve aging adults, people with physical disabilities, people with intellectual or developmental disabilities, people with brain injuries, or people with chronic illnesses. Some programs serve adults only, some serve children, and some serve both.

Many programs also require that you meet a certain level of care. In general, that means that without in-home support, you might otherwise need care in a nursing facility or similar setting. How that is measured depends on your state.

One more thing to know: some programs, particularly waiver programs, can limit how many people enroll. That means some states have waiting lists for certain programs while others do not.

In some programs, self-direction applies mainly to personal care, such as help with bathing, dressing, meals, and household tasks. Other programs allow more. In New York’s CDPAP, for example, a personal assistant can provide the kinds of services normally provided by a personal care aide, home health aide, or nurse. Some programs also allow you to use part of your budget for approved goods and services, like certain equipment or home modifications that support your independence. What is covered depends on your program and your approved plan.

CMS describes two main types of decision-making authority in self-direction:

• Employer authority: You recruit, hire, train, and supervise the people who provide your care
• Budget authority: You make decisions about how the Medicaid funds in your individual budget are spent

Some programs offer employer authority only. Others offer both. In Arkansas, for example, participants in the self-direction model receive an allowance for their personal assistance services and can decide how it is spent, including whether to use part of it for other approved items.

States use different methods to decide how much support you receive. In many programs, a case manager or assessor completes an evaluation of your needs using a state-approved tool. The result may be a set number of approved care hours, a dollar budget, or both.

In California’s Self-Determination Program, for example, a participant’s individual budget is generally based on what their services would have cost through the traditional Regional Center model.

Pay rates for caregivers also vary. In some programs, you can decide how much to pay your caregiver and negotiate a rate within your budget. In others, the program sets the rate.

One of the biggest draws of self-direction is being able to hire someone you already know and trust, such as a friend or family member. Most programs allow this, but the rules about which family members can be paid differ.

In New York’s CDPAP, for example, a personal assistant can be a friend or family member as long as they are not the consumer’s spouse, their designated representative, or the parent of a consumer under age 21. Other states draw these lines differently, especially when it comes to spouses, parents of minor children, and legal guardians. Some programs also have their own background check, training, or health screening requirements for caregivers.

If you hope to hire a specific person, ask about this early. Our post on how to hire and manage a caregiver under self-direction walks through what comes next once you have someone in mind.

States also choose how the employer relationship is structured. The two most common self-direction models are:

• Fiscal/Employer Agent (F/EA): You, or a representative acting on your behalf, are the common-law employer of your caregiver. A Financial Management Services provider handles payroll, tax filing, and related paperwork for you.
• Agency with Choice (AWC): An agency serves as the legal employer of your caregiver, while you still choose your caregiver and direct their day-to-day work.

See also: self-directed vs. agency home care.

Most self-directed programs work with a Financial Management Services (FMS) provider, sometimes called a fiscal intermediary or fiscal employer agent. This organization handles the administrative side of self-direction, like processing caregiver payroll and managing employment taxes.

How FMS providers are selected varies. Some states contract with a single statewide provider for a program. Others approve several providers and let participants choose. Your case manager or program materials should tell you which FMS options are available to you.

Electronic visit verification (EVV) is a system that confirms when and where in-home care is provided. Under the federal 21st Century Cures Act, states must use EVV for Medicaid personal care services and home health care services that require an in-home visit.

While the requirement is federal, states decide how to put it in place. Whether your caregiver clocks in and out with a mobile app, a phone line, or another method depends on your state and program.

Most programs connect you with someone who helps you plan and manage your services, but their titles vary. Depending on your state and program, this person might be called a case manager, service coordinator, support coordinator, support broker, or independent facilitator.

Their exact role differs too. In Pennsylvania’s ODP program, a Supports Coordinator helps you develop your Individual Support Plan. In California’s SDP, participants can choose an independent facilitator to help with planning and budgeting.

In some states, self-direction is coordinated directly through the state Medicaid agency or another state department. In others, it is offered through managed care organizations (MCOs), which are health plans that contract with the state to coordinate Medicaid services. If your coverage comes through an MCO, your health plan may be your starting point.

Because so much varies, the best approach is to get clear answers about your specific program. Here are questions worth asking your state Medicaid agency, case manager, or health plan:

1. What self-directed programs are available in my state? Ask for the program names so you can research them directly.
2. Am I eligible? Confirm the Medicaid, level of care, age, and diagnosis requirements.
3. Is there a waiting list? If so, ask how to get on it and how priority is determined.
4. Which services can I self-direct? Find out whether the program covers personal care only or also includes other services or goods.
5. Who can I hire? Ask specifically about family members, including spouses and parents.
6. How is my budget or number of hours determined? Ask how often it is reviewed and how to request changes if your needs change.
7. Which employer model does the program use? Find out whether you or an agency will be the employer of record.
8. Who is the FMS provider, and do I have a choice? Ask whether your state uses one statewide provider or lets you choose from several.
9. How does EVV work in my program? Ask whether your caregiver will clock in and out with a mobile app, a phone line, or another method.
10. Who will help me plan and manage my services? Find out what that person is called, such as a case manager or support coordinator, and how they can help you.

Once you have these answers, the next steps become much clearer.

Your state Medicaid agency’s website is a good place to start, since most states publish information about their home and community-based services. If you already receive Medicaid services, your case manager or health plan can also tell you which self-directed programs you may qualify for. You can also browse self-directed care programs by state to see program names, the populations they serve, and which state agency oversees each one.

Explore Programs by State

If you are still at the very beginning, this step-by-step overview of how to start self-directed care explains the general path from Medicaid enrollment to hiring a caregiver. You can also find quick answers in our blog, “Your Biggest Self-Direction Questions, Answered.”

Self-direction can look different depending on where you live, but the goal is the same everywhere: helping you or a loved one receive support at home from people you trust. If you are wondering whether self-directed care is a good fit, take our short questionnaire to see your next steps.

Take the Questionnaire

PPL (Public Partnerships LLC) is a Financial Management Services company focused entirely on self-directed care. PPL is not a home care agency and does not assign caregivers or provide direct care. Instead, PPL handles the administrative side of self-direction, including payroll, taxes, enrollment paperwork, and compliance, so participants and the caregivers they choose can focus on care. PPL supports around 50 self-directed programs across the country and has managed more than 700,000 participant and caregiver relationships.

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