Alternatives to Hiring a Private-Duty Home Care Agency in New Hampshire

If you're looking at private-duty home care agencies in New Hampshire and the $35 to $50 per hour price tag is unsustainable, here's the direct answer: the Choices for Independence (CFI) waiver is the primary alternative, funding the same personal care services through Medicaid at no cost to families who qualify. For families who don't qualify or are waiting on the CFI waitlist, self-directed caregiving, Title XX Block Grant services, and the National Family Caregiver Support Program provide real coverage at zero or reduced cost. The right option depends on your parent's income, clinical needs, and how quickly you need help.

The Six Main Alternatives

1. CFI Waiver — Medicaid-Funded Home Care

The Choices for Independence waiver is New Hampshire's 1915(c) Home and Community-Based Services program. It funds personal care aides, homemaker services, adult day programs, home modifications, emergency response systems, and case management — essentially the same services a private agency provides, paid by Medicaid.

Financial eligibility: Gross monthly income up to $2,982 and countable assets up to $8,500 (the effective categorical limit after New Hampshire's resource disregard under He-W 856.07). The primary residence is exempt up to $752,000 in equity.

Clinical eligibility: Your parent must need hands-on or direct supervisory assistance with at least two Activities of Daily Living, as determined by a Medical Eligibility Assessment conducted by Acentra Health. This is the gate that catches families off guard — parents with cognitive decline often mask during the assessment, presenting as more functional than they actually are.

The catch: The CFI waiver is a capped program, not an entitlement. When all approximately 5,400 slots are filled, new applicants are waitlisted. And the workforce shortage at the center of the Fitzmorris v. Weaver litigation means that even approved participants sometimes can't find agencies with enough staff to fill their authorized hours.

The Aging in Place in New Hampshire Guide walks the entire CFI application process — financial eligibility worksheets, document preparation, MEA preparation with a 14-Day Functional Care Log, and the step-by-step NHEasy portal submission sequence.

2. Self-Directed Care Under the CFI Waiver

This is the alternative most families don't know about. Once enrolled in the CFI waiver, your parent can choose self-directed care instead of receiving services from an agency. Under this option, you hire a family member, friend, or other trusted person as a paid caregiver at up to $20 per hour. A fiscal management service handles payroll, taxes, and workers' compensation.

Why it matters: When agency staffing shortages leave authorized hours unfilled — the core systemic failure documented in the Fitzmorris litigation — self-direction means you're not waiting for an agency to find someone. You hire the person your parent already trusts, and they get paid for the work they may already be doing unpaid.

Requirements: You must request self-direction through your Case Management Agency, select an approved fiscal agent, and if hiring a spouse, confirm eligibility with DHHS DLTSS. Background checks are required for all hired caregivers.

The guide's Self-Directed Care Enrollment Checklist walks every step of this process, from the initial request through payroll setup.

3. Title XX Social Services Block Grant Home Care

If your parent doesn't meet CFI clinical eligibility (the 2-ADL threshold) but still needs help at home, Title XX provides a backup. The Social Services Block Grant funds personal care, homemaker services, and adult day care through the same county-based service network.

Income limit: $1,645 per month for 2026 — tighter than Medicaid's $2,982 cap.

No clinical assessment required: You don't need to pass the Medical Eligibility Assessment to access Title XX services.

Limitation: Funding is limited and varies by county. Title XX is not an entitlement — when the block grant allocation runs out, services may be reduced or waitlisted.

For families whose parent's income is low enough but whose clinical needs don't reach the 2-ADL threshold, this can provide meaningful support — enough aide hours to cover the tasks your parent struggles with without the rigorous medical assessment process.

4. National Family Caregiver Support Program (NFCSP)

If you're the one providing care, the NFCSP supports you directly — with respite care, supplemental services, counseling, and training. Administered through ServiceLink and the Area Agencies on Aging under the Older Americans Act.

No income test: The program is open to caregivers of an adult age 60 or older or a person with dementia at any age, regardless of the care recipient's financial situation, subject to local availability.

What you get: Respite care (someone else steps in so you can rest), supplemental services that help with caregiving tasks, information and assistance, and access to caregiver training. The specifics vary by county and available funding.

Best for: Family caregivers who are providing unpaid care and need a break — not a replacement for daily care, but a meaningful supplement that can prevent burnout while you work through the CFI application process or bridge a waitlist gap.

Contact your county ServiceLink office to ask about local enrollment and availability.

5. Medicare Home Health (Short-Term Only)

Medicare is not a substitute for ongoing home care — it covers skilled nursing and therapy after an acute event, not the daily custodial assistance that aging in place requires. But if your parent was recently hospitalized or has a new medical condition that requires skilled intervention, Medicare Home Health can provide visiting nurses, physical therapists, and occupational therapists at no cost.

Requirements: Your parent must be homebound, need skilled care (not just help with ADLs), and have provider certification and a plan of care. Services are intermittent — a few visits per week, not daily aide hours.

Why it's on this list: Families sometimes confuse Medicare Home Health with long-term home care. They're fundamentally different programs. Medicare covers clinical recovery; Medicaid (via the CFI waiver) covers ongoing daily assistance. Understanding which one applies to your parent's current situation prevents you from pursuing the wrong path.

6. Direct-Hire Private Caregiver

If Medicaid programs don't fit (income too high, no waitlist slot, clinical threshold not met) and agency rates are too expensive, hiring a private caregiver directly cuts the cost roughly in half. You pay the caregiver $15 to $25 per hour instead of the $35 to $50 an agency charges — the difference is the agency's overhead, training, insurance, and profit margin.

You become the employer: This means managing payroll, withholding taxes, checking insurance requirements, and handling scheduling. At 20 hours per week, the nominal rate difference is about $200 to $700 per week before employer costs; actual savings vary with hours and rates.

Finding caregivers: Care.com, local caregiver registries, and word-of-mouth through faith communities and senior centers are the common channels. Always run a background check and verify references.

Risk: If the caregiver is injured in your parent's home, you may face personal liability exposure if required coverage is not in place. This is the logistics burden that makes agencies attractive despite the premium.

How to Choose

Start by checking CFI eligibility — it's the most comprehensive and lowest-cost option. If your parent qualifies, the only question is whether an agency or self-directed care works better for your situation. If they don't qualify or the waitlist is long, layer the alternatives:

• Title XX for basic aide hours if income allows
• NFCSP for caregiver respite — no income test, fast access
• Medicare Home Health if there's a skilled care need after an acute event
• Direct hire if you need daily hours and can manage the employment logistics
• Agency care on a limited schedule (10–15 hours/week instead of 40) as a last resort if budget permits

The Aging in Place in New Hampshire Guide maps all of these options in the Non-Medicaid Safety Net Tracker, with eligibility thresholds, contact numbers, and application steps for each program. It's designed for exactly this situation — when the first option you tried doesn't work, and you need to know what comes next.

Who This Is For

• Families paying $35–$50/hour for private-duty agency care and looking for a sustainable alternative
• Adult children whose parent may qualify for Medicaid home care but who haven't applied yet
• Caregivers on the CFI waiver waitlist who need interim support programs
• Families whose parent was denied CFI clinical eligibility and need non-Medicaid options

Who This Is NOT For

• Families whose parent needs skilled medical care at home (that's Medicare Home Health, not the programs on this list)
• Families looking for assisted living or nursing facility placement — these programs fund in-home care
• Parents who are fully independent and don't need ADL assistance

Frequently Asked Questions

Can my parent use multiple programs at the same time?

Yes, with limitations. A parent enrolled in the CFI waiver can also use Medicare Home Health for skilled needs (nursing, therapy) that the waiver doesn't cover. NFCSP respite can supplement waiver services. What you can't do is bill two programs for the same service on the same day — Medicaid and Title XX can't both pay for the same aide hours.

How much does the CFI waiver actually cover in aide hours?

The Plan of Care developed by the Case Management Agency determines the authorized hours based on assessed need. There's no fixed cap published by the state — it's individualized. Some participants receive 10 hours per week; others receive 40+. The Fitzmorris litigation specifically addresses the gap between authorized hours and actually delivered hours due to workforce shortages.

Is self-directed care available to everyone on the CFI waiver?

Self-direction is an option, not a requirement. You must request it through your Case Management Agency, and you need to select an approved fiscal management service. There are rules about spousal hiring — DHHS DLTSS must confirm eligibility. Not every case manager proactively offers this option, so you may need to ask for it specifically.

What happens if a private caregiver I hire directly gets hurt in my parent's home?

Direct hiring makes you the employer. Before work begins, confirm New Hampshire's workers' compensation and payroll requirements for your arrangement; an injury can create personal liability exposure if required coverage is not in place.

How long can my parent stay on Title XX services?

There's no fixed time limit, but Title XX is funded through annual block grants. When the allocation is spent, services may be reduced or waitlisted until the next fiscal year. It's a bridge, not a permanent solution — though some families use it for years when Medicaid eligibility doesn't fit.

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