Consumer Directed Services Virginia — How Family Caregivers Get Paid Through Medicaid

You've been bathing your mother, managing her medications, driving her to appointments, and cooking her meals for the past two years. You cut your work hours to do it. And the whole time, there's been a Virginia Medicaid program that could have been paying you for exactly this care.

Consumer Directed Services (CDS) is a model within Virginia's Cardinal Care/CCC Plus Medicaid waiver that allows eligible individuals to hire, train, and supervise their own caregivers — including family members. Instead of the managed care organization assigning an agency aide, the Medicaid beneficiary (or their authorized representative) chooses who provides their care and directs how that care is delivered.

How Consumer Directed Services Work

Under the CDS model, the Medicaid beneficiary becomes the "employer" of their caregiver. A designated Employer of Record (EOR) handles the administrative side — payroll, taxes, workers' compensation — so the family doesn't have to navigate employment law.

The structure:

1. The beneficiary (your parent) is approved for home and community-based services through the CCC Plus waiver
2. Your parent (or their authorized representative — which can be the agent under a power of attorney or a court-appointed guardian) selects a family member or other individual as their caregiver
3. The Employer of Record processes timesheets, issues paychecks, withholds taxes, and manages workers' comp insurance
4. Medicaid funds the care hours through the managed care organization (MCO) that manages your parent's Cardinal Care plan

Who Can Be a Paid Caregiver

Most family members qualify as CDS attendants:

• Adult children — yes
• Grandchildren — yes
• Siblings — yes
• Parents — yes (for adult children needing care)
• Nieces, nephews, cousins — yes
• Friends and neighbors — yes

The critical exception: spouses are excluded. Virginia Medicaid does not allow a beneficiary's spouse to receive payment as a personal care attendant through consumer directed services. This is a federal Medicaid rule that Virginia has not waived.

The caregiver must be at least 18 years old, pass a background check, and be physically and mentally capable of providing the required care.

Eligibility Requirements

Your parent must qualify for the CCC Plus waiver, which requires:

Clinical eligibility: A Long-Term Services and Supports (LTSS) screening using the Uniform Assessment Instrument (UAI) must determine that your parent needs a nursing facility level of care. This means they're dependent in multiple activities of daily living (bathing, dressing, toileting, transferring, eating) and/or have significant cognitive impairments.

Financial eligibility: Countable assets must be at or below $2,000 (individual) or within spousal impoverishment protections. Monthly income must be at or below $2,982 (300% of the federal SSI rate). If income exceeds this limit, Virginia's medically needy spend-down pathway may apply — your parent can qualify by showing that unpaid medical bills equal or exceed their excess income.

Choice of CDS: When the MCO develops the person-centered service plan, the beneficiary (or their representative) must specifically request the consumer directed model rather than agency-directed care.

What the Caregiver Gets Paid

CDS rates vary by the MCO managing the plan and the service hours authorized. Typical rates for personal care attendants range from $13 to $18 per hour depending on the region, MCO, and service type. The authorized number of hours is determined by the service plan based on the UAI assessment — not by what the family requests.

The Employer of Record handles payroll processing, so the caregiver receives a regular paycheck with taxes already withheld. The caregiver is treated as a household employee for tax purposes.

The Employer of Record — Your Administrative Partner

The EOR is a fiscal agent contracted by Virginia DMAS to handle employment administration. The EOR:

• Issues paychecks to the caregiver based on submitted timesheets
• Withholds federal and state income taxes, Social Security, and Medicare
• Maintains workers' compensation insurance
• Processes wage changes and handles employment paperwork

Your parent (or their representative) is responsible for hiring, training, scheduling, and supervising the caregiver. The EOR handles the paperwork — but the care relationship is between the family.

How This Connects to Legal Authority

Here's where consumer directed services intersect with the legal authority framework. If your parent has cognitive decline and can't independently manage the CDS program — selecting a caregiver, approving timesheets, directing care activities — someone needs legal authority to act as their authorized representative.

That authorized representative can be:

• A power of attorney agent — if your parent executed a valid durable financial and healthcare POA while they had capacity
• A court-appointed guardian — if capacity was already lost and the family went through the guardianship process

Without one of these, the MCO may not allow the family to select the CDS model, because there's no legally authorized person to manage the employer relationship.

This is one of the most common reasons families seek a power of attorney specifically: they want to enroll their parent in consumer directed services and need someone legally authorized to manage the program.

Steps to Enroll

1. Confirm Medicaid eligibility — your parent must be enrolled in Cardinal Care through a managed care organization
2. Request an LTSS screening — contact the local Department of Social Services or your parent's MCO care coordinator
3. Meet clinical criteria — the UAI assessment must establish nursing facility level of care
4. Request CDS in the service plan — during the person-centered planning meeting, specify that you want consumer directed services rather than agency care
5. Identify the caregiver — name the family member who will provide care and complete background check requirements
6. Enroll with the EOR — complete the fiscal agent paperwork to establish the employment relationship

The Virginia Power of Attorney & Guardianship Kit includes the legal authority documents families need to serve as authorized representative in the CDS program, alongside the CCC Plus waiver eligibility worksheets that help determine whether your parent qualifies for Medicaid-funded home care.

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