Consumer-Directed Care Maryland: How to Hire Your Own Caregivers Through Medicaid

What Consumer-Directed Care Actually Means in Maryland

Maryland gives Medicaid home care participants a choice in how their personal care gets delivered. The default is the agency model — a licensed Residential Service Agency (RSA) sends its own employees to your parent's home on a set schedule. The alternative is consumer-directed care, where your parent remains the common-law employer and an authorized representative can help manage the arrangement. The participant recruits, hires, schedules, trains, and supervises their own personal care assistants.

This isn't a marginal option. For families where an adult child, sibling, or even a spouse has been providing unpaid care for months, consumer-directed care converts that informal arrangement into a paid, Medicaid-funded position. The caregiver gets a paycheck. The care recipient gets someone they already trust. And the state pays for it through the same program that would otherwise fund agency workers.

Consumer-directed care is available under two Maryland Medicaid programs: Community First Choice (CFC) and Community Personal Assistance Services (CPAS). Both are state plan entitlements with no waitlist — if your parent qualifies medically and financially, they have a legal right to these services.

How the Employer Model Works

When your parent elects consumer-directed care, the state establishes an individualized personal budget based on the clinical needs identified during their interRAI functional assessment. That budget defines how many hours of care per week are authorized and the hourly rate.

Your parent uses that budget to hire their own staff. They choose who provides the care, set the schedule, direct the tasks, and can terminate the arrangement. In employment law terms, the participant is the common-law employer.

But here's the practical safeguard: nobody expects an 80-year-old with dementia to manage payroll taxes. Maryland mandates the use of an independent Fiscal Management Services (FMS) provider. The FMS handles:

• Criminal background checks on all hired caregivers
• Employment paperwork (W-4, I-9)
• Processing timesheets submitted through LTSSMaryland (the state's electronic visit verification system)
• Withholding federal and state income tax, Social Security, and Medicare taxes
• Issuing semi-monthly paychecks to the caregivers
• Workers' compensation coverage

The participant directs the care. The FMS handles the bureaucracy. More on choosing an FMS provider in our post on fiscal management services in Maryland.

Who You Can Hire — and the Spouse Question

Under Community First Choice, participants can hire adult children, other relatives, or friends as paid personal care assistants. The caregiver must pass a criminal background screening, but there's no professional certification requirement for non-medical personal care tasks.

The spouse question is program-specific:

• Community First Choice: CFC regulations do not explicitly exclude a spouse from serving as a paid personal assistant. A husband or wife can serve as the paid caregiver under the self-directed option, subject to local supports planning approval. This makes CFC the most flexible program for spousal caregiving.
• Increased Community Services (ICS): A strict spousal exclusion applies under COMAR 10.09.81.13B. A spouse or the parent of a minor dependent child cannot serve as a paid attendant.
• CPAS: The rules on paid spousal caregiving remain unsettled in published state materials. Confirmation requires a case-by-case determination from the assigned Supports Planning Agency.

One absolute restriction across all programs: a family member who also serves as the participant's legal decision-maker — court-appointed guardian, designated healthcare agent, or active financial Power of Attorney — cannot simultaneously be their paid caregiver. If your parent needs both legal representation and a paid family caregiver, those roles must be held by different people.

Getting Started with Consumer-Directed Care

1. Determine program eligibility. Your parent must qualify for CFC or CPAS — meaning they meet the financial limits ($2,500 asset cap, income either below $350/month or qualifying through the Medically Needy spend-down) and the clinical threshold (nursing facility level of care for CFC, or at least one ADL limitation for CPAS).

2. Contact Maryland Access Point at 1-844-627-5465 to initiate screening and request a clinical assessment through the local health department.

3. Choose the consumer-directed model when your assigned Supports Planning Agency drafts the Plan of Service. This is where you formally elect self-direction over agency care.

4. Select an FMS provider. The Supports Planner will provide a list of approved FMS organizations operating in your county.

5. Recruit and onboard your caregiver. The FMS runs the background check and sets up the employment relationship. Your caregiver begins providing services and submitting timesheets.

When Consumer-Directed Care Makes Sense — and When It Doesn't

Consumer-directed care works best when the family already has a reliable caregiver lined up — typically an adult child who has been providing unpaid care and can formalize the arrangement. It also works well for families in rural counties where RSA staff availability is limited.

It's a harder fit when the care recipient has advanced dementia and no family representative to manage the employment relationship, or when the clinical situation requires skilled nursing that an unlicensed family caregiver can't safely provide. In those cases, the agency model (with a licensed RSA providing trained staff) is the safer choice.

The Maryland home care navigation guide covers both care delivery models in detail — including how to structure the transition from unpaid family caregiving to a formal Medicaid-funded arrangement without triggering look-back violations or disrupting existing benefits.

See more Maryland guides →