Understanding Self-Directed Care: What It Is and How it Works

Last Updated on September 3, 2026

Self-directed care is a powerful choice that lets you or your loved one maintain control over your care. With self-direction, you have the freedom to live in your home and community, as opposed to institutionalized care or having an agency send possibly different personnel every week, and decide who delivers your care, such as friends or approved family members. 

Self-direction is a home care model that puts you or your loved one in control. Instead of an agency or care facility deciding who helps you and when, you choose who provides your support, and where and when you receive it. It’s built for people with intellectual or developmental disabilities, chronic illness, and aging adults who want to stay in their own home and community, usually with support funded through Medicaid or state programs. 

Self-direction may also be called consumer direction, participant direction, or self-determination. 

Self-direction typically means you or your representative hire someone you know and trust to provide you with the services and support you need to remain in your home and community. This process means that you (or your representative) are responsible for employing and paying the person who takes care of you, usually with Medicaid or state funds.

Learn the difference between self-directed vs. agency home care.

Say you want to hire your friend to come help you around the house and transport you to your doctor’s appointments. One of the benefits of self-directed care is getting the personalized help you need from a trusted person while your friend is compensated for their time. This relieves the burden on the participant, but also the friend who was likely to step in and help anyway, but without pay.

In agency and institutionalized care, you usually don’t get to choose who supports you and there may be a different stranger coming to you each time, where you must reexplain what you need to a new person again. Self-Direction helps keep you at home and supports you in your community by offering these services! 

“Self-direction promotes personal choice and control over the delivery of waiver and state plan services, including who provides the services and how services are provided. For example, participants are afforded the decision-making authority to recruit, hire, train and supervise the individuals who furnish their services.” (Self-Directed Services, Medicaid.gov) 

Federal and state regulations require that key programs and supports be in place to ensure that self-directed care works as mandated: 

• Person-Centered Planning: You specify the support and services you need to be healthy and live a full life.
• Individualized Service Plan (ISP): Your case manager may help you create a service plan (sometimes called an ISP) that ensures you have the care, support, and services you need to live in your home and community. This plan specifies what you need from your care/support worker, how this fits within your individualized budget, and what you will do in the event your care/support worker is unavailable.
• Support Systems: The federal government requires your state to have systems of support in place that ensure successful delivery and management of your self-directed care. These support systems include assistance with developing your ISP, budget advice, resources/training that can help you experience self-direction success, and advice on using an FMS for payroll. 
• Financial Management Services (FMS): An FMS provider helps you manage your support and services. This includes helping with employee enrollment and background checks, paying your care/support workers and service vendors on your behalf, budget management and timesheet approval.
• Employer Authority: Many self-directed programs give you what is called “employer authority”. This means you get to choose the people who provide your care, including recruiting, hiring, training, scheduling, and, if needed, replacing your care/support workers. In most programs, you can hire someone you already know and trust, such as a friend or an approved family member. You are the boss, and your workers answer to you rather than to an agency.
• Budget Authority: This means you have a say in how your approved Medicaid budget is spent. Within your program’s rules, you decide how to allocate funds across the support and services that help you live at home. Not every program offers budget authority, and some offer employer authority only. Whether you have one, the other, or both depends on your program and what state you live in.
• Electronic Visit Verification (EVV): Electronic visit verification, or EVV, is a system that records when your care/support worker starts and ends each visit. It comes from the 21st Century Cures Act, a federal law that requires states to use EVV for Medicaid-funded personal care and home health services. Your worker usually clocks in and out using a mobile app or a phone system at the start and end of each shift. EVV is a normal part of self-directed care today, and your FMS provider can show you and your workers how it works.

Together with your case manager (counsellor, support broker, service/care coordinator), you determine how best to use your approved budget to ensure you get the care, support, and services you need.  

An FMS provider is appointed to help you manage your support and services, all within your approved Medicaid budget.  

When thinking about self-direction and deciding if it is right for you or your loved one, it’s important to know that self-direction gives you control and freedom with: 

• Support: Help with daily living such as bathing, medical care, cooking, cleaning, etc. 
• Services: Funds to support personalized needs such as transportation, home modifications, physical therapy, community classes, skills training, etc.  

Note: Every self-direction program has a list of approved care services. Please check your program guidelines to confirm the support and services available to you within self-direction.

These 10 benefits of self-directed care underscore how self-directed makes it possible for you or your loved one to thrive and succeed: 

1. Live in your own home and community and have direct access to your local support systems.
2. Flexible and personalized services and care that mesh with your needs, interests, and lifestyle. Self-direction gives you the flexibility to adjust your services as your needs change over time.
3. Creativity and freedom to be involved in your community. Self-direction means you get what you need – for example, the opportunity to volunteer in your community, attend exercise classes at your local gym, skill development training, etc. There are no restrictions on what your self-directed program looks and feels like.
4. Personalized care from a care/support worker that you know, trust, and can relate to. This can be a friend, family member, and someone who shares similar interests as you. The support a chosen in-home caregiver can provide has huge emotional benefits. 
5. Control over your care. You do not need to rely on an agency to find, hire, and manage your care/support workers. You are the boss, which means your care/support workers answer to you.  
6. Improved access to care/support workers in rural areas. Because you can hire your friends or family members to deliver your care, you have immediate access to the care you need, regardless of where you live. 
7. Cost-effective and the best value for your money. Many people are concerned about the cost of in-home care or how the money is used. This way, you are in charge of your budget and how you spend it, within your program’s rules, so you can make sure you are getting what you need and when you need it.
8. Better value for your money translates to more support and care. With no agencies fees to pay, you have more money to allocate to your care.  
9. Improved quality of life for you and your loved ones. Self-direction gives you and your family members enhanced quality of life and peace of mind over your care and support.
10. Wherever you live and whatever your needs – you have control over your care. Self-direction is available to children, adults, veterans, and the elderly who qualify for a Medicaid waiver or state program that offers it. People with physical or intellectual disabilities and people with mental health issues can use self-directed care.  

Self-directed care is generally available to people who qualify for Medicaid long-term services and supports and need help to live safely at home. This often includes older adults, people with physical disabilities, people with intellectual or developmental disabilities, and people managing chronic conditions. Children, adults, and veterans all use self-direction, so it is not limited to any one age group.

Eligibility rules are set at the state level, so the exact requirements depend on where you live and which program you apply to. The best way to confirm whether you or a loved one qualifies is to check your state’s program details or reach out for help reviewing your options.

Self-directed care is not one single national program. It is a model that each state builds and runs in its own way, which means the details can look different depending on where you live. Knowing this upfront helps set the right expectations before you enroll.

States offer self-direction through different Medicaid pathways, and each pathway has its own rules about who can participate and which services can be self-directed. Because of this, two people in two different states may both self-direct their care while following very different guidelines. You do not need to know these pathways to get started. Your state’s program materials and your FMS provider can explain which rules apply to you.

Some important details vary depending on your state and program:

• The program name. For example, New York’s self-directed program for personal care is known as CDPAP. That’s not what it’s called in every state.
• Which services you can self-direct and how your budget is structured.
• Whether you have employer authority, budget authority, or both.
• Who you are allowed to hire, including any rules about paying a spouse, parent, or other close family member.

Because these rules differ, it is best to confirm the specifics for your state rather than assume that another state’s program works the same way. 

Explore Programs by State

An FMS or Financial Management Services provider has a critical role in the success of self-directed care for you or your loved one. As Medicaid laws in most states can prohibit direct cash payments to individual self-directing program participants or their representatives, states or managed care organizations appoint an FMS provider company to assist. 

The role of an FMS in self-directed care includes: 

• Helping you prepare for your role as an employer of care/support workers. 
• Assistance with completing federal and state required enrollment forms and completing background checks. 
• Payment of your care/support workers’ payroll taxes on your behalf.  
• Payment of your service vendors on your behalf. 
• Assistance with budget management and approval of your care/support workers’ time sheets.  

Getting enrolled in self-directed care requires you or your loved one to fill in a number of enrollment forms. These forms ensure that all federal and state guidelines regarding how money is spent on your care are followed.

The enrollment process collects, reviews, and verifies all program-required paperwork and information so you can hire and pay people to provide your care.

Enrollment options vary by state, and your state might not support every option below:

1. Online enrollment. Complete your paperwork through a secure web portal.
2. Paper-based enrollment. You and your care/support workers receive the required paperwork to complete and review, with in-person help available in some states.
3. Phone-based enrollment. Like paper-based enrollment, except the review is conducted over the phone.

Self-direction gives you control over your care, and it works best when you or a representative are ready to take an active role in choosing and managing your support. If that sounds like the right fit, the next step is to see which programs are available to you.

Still not sure? Read our blog: Your Biggest Self-Direction Questions Answered.

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PPL (Public Partnerships LLC) is a Financial Management Services provider that supports self-directed care across roughly 50 programs nationwide. PPL doesn’t provide direct care or assign in-home caregivers. Instead, PPL handles the administrative side of self-direction, including payroll, tax compliance, and enrollment, so participants can hire the people they trust and stay in the home and community they love.

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