Introduction
Medicaid’s Consumer Directed Care (CDC) options let seniors make some of their own long-term care choices, including hiring and paying family members as caregivers in some cases. Exactly how much decision-making power beneficiaries are given depends on the program, but all 50 states and Washington, D.C. have at least one consumer directed option for Medicaid in-home care.

What is Consumer Directed Care?

Through Consumer Directed Care, Medicaid recipients have greater control over some of their in-home, long-term care benefits. This control can range from having a few more options when it comes to medication, to having their own healthcare budget and the authority to spend it, including hiring and training personal caregivers of their choice. The scope of the Consumer Directed Care will be spelled out in the Medicaid recipient’s long-term care plan, and it depends on the state and its assessment of the Medicaid recipient’s medical needs.

CDC benefits can be provided in the Medicaid recipient’s home, the home of a loved one and, in many states, an assisted living residence or adult foster home. They can not be used in nursing homes.

Consumer Directed Care was previously referred to as cash and counseling. It may also be called self-directed care, participant direction, self-administered services and consumer directed services.

Who Can Be Caregivers?

Caregivers hired via Medicaid’s Consumer Directed Care options can be professionals, but they don’t have to be. However, non-professionals may have to undergo a background check, take some training classes or earn a certificate to be paid as a caregiver by Medicaid, depending on the state.

These caregivers can be family members or friends. This is a significant benefit for numerous seniors and their families since so many family members are already providing care but not getting paid for it.

Spouses can even be paid by Medicaid as caregivers via consumer directed care in the following 27 states: Alabama, California, Colorado, Delaware, Florida, Hawaii, Indiana, Iowa, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Utah, Vermont, and Wisconsin.

Additional Support

If a Medicaid long-term care recipient can not make their own choices (someone with advancing Alzheimer’s disease or another dementia, for example), a proxy can make care choices for them. This would usually be a spouse, or an adult child or another family member with some Power of Attorney authority regarding the senior’s medical decisions and/or financial situation.

The state will offer financial advising support for Consumer Directed Care beneficiaries who are given their own budget. This can include help with managing a budget, tracking hours for caregivers, issuing paychecks, calculating taxes and other withholdings, and assessing cost options for medications and medical equipment.

Medicaid Programs with Consumer Directed Care

Consumer Directed Care is available through Home and Community Based Services (HCBS) Waivers and regular Medicaid for seniors, as well as the Structured Family Caregiving programs in some states. As mentioned above, CDC does not apply to Medicaid’s nursing home coverage. However, Nursing Home Medicaid beneficiaries are allowed to choose which nursing home they go to, as long as the facility is approved for Medicaid and has an available space.

Home and Community Bases Services (HCBS) Waivers

Most states have one or more HCBS Waiver that will cover long-term care benefits for recipients who live in their own home, the home of a loved one or, in some states, an assisted living residence. Many of these HCBS Waivers programs include a Consumer Directed Care option, but exactly how much decision-making power is given to the Medicaid recipient can vary by state. Some may only provide a greater range of choices when it comes to providers or medical equipment, others may give the recipient control over their own budget. There can be other state variations, like in New Mexico, where beneficiaries need to receive 120 days of care from a licensed, state-provided caregiver before they can self-direct their care.

To be eligible for most HCBS Waivers, applicants need to require a Nursing Facility Level of Care (NFLOC). How a NFLOC is defined and measured can also vary by state, but in general it means the kind of 24-hour care and supervision that is associated with nursing homes. A few HCBS Waivers only require applicants to be at risk of needing a NFLOC. The financial eligibility criteria for HCBS Waivers can also vary by state, but in most states in 2025 the individual asset limit is $2,000 and the individual income limit is $2,901/month.

HCBS Waivers are not an entitlement. Instead, they have a limited number of enrollment spots. When these spots are full, additional applicants are placed on a waitlist. How these waitlists are prioritized and organized depends on the state. To learn more about waitlists, eligibility criteria and the consumer directed care benefits available through HCBS Waivers in your state, consult with a Medicaid planning professional.

Regular Medicaid for Seniors

Also known as state Medicaid or Aged, Blind and Disabled (ABD) Medicaid, regular Medicaid for seniors offers consumer directed long-term care options in many states. The scope of these regular Medicaid consumer directed options also depends on the state, but they are focused on personal care services and give beneficiaries the ability to hire caregivers of their choice.

Consumer Directed Care via regular Medicaid for seniors is often offered through one of these programs: Community First Choice Option, Self-Directed Personal Assistant Services (PAS) State Plan Option (may also be a benefit of HCBS Waivers in some states) and the Home and Community Based Services States Plan Option.

Regular Medicaid is an entitlement, which means all eligible applicants are guaranteed coverage. To be eligible for long-term care through regular Medicaid, seniors must show a specific need for that care. This is a less strict requirement than needing a NFLOC. The financial eligibility criteria for regular Medicaid varies by state, but in 2025 the individual asset limit in most states is $2,000 and the individual income limit ranges from $967/month to $1,795/month, depending on the state.

Structured Family Caregiving

Also known as adult foster care, adult family living and coordinated caregiving, Structured Family Caregiving (SFC) is another way for Medicaid recipients to direct their own care. SFC programs allow recipients to pick their own caregivers, including family members, although spouses can not be caregivers in SFC programs. SFC will pay previously unpaid caregivers to provide 24-hour supervision, homemaker services and assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) to Medicaid recipients. These caregivers most commonly adult children, but they can be any relative or non-relative, other than spouses.

The caregiver and the care recipient must live together to be eligible for SFC benefits. Medicaid will provide the caregiver with training and respite care.

SFC programs are available in the following states through regular Medicaid for seniors or HCBS Waivers: Connecticut, Georgia, Indiana, Louisiana, Massachusetts, Missouri, Nevada, North Carolina, Rhode Island and South Dakota.