Self-Directed Attendant Care in South Carolina Medicaid

Most people who qualify for South Carolina's Community Choices Waiver assume they'll be assigned a home care agency — and that the agency picks the caregiver. That's the default path, but it's not the only one. The self-directed attendant care option lets the waiver participant (or their authorized representative) hire, train, schedule, and supervise their own personal care worker. That worker can be a qualified family member or another worker permitted under the waiver rules and fiscal intermediary's requirements.

The difference matters because agency-assigned aides rotate, cancel shifts, and don't always know your parent's routines. Self-direction puts hiring decisions in the family's hands.

How Self-Directed Care Works Under the Community Choices Waiver

Self-directed attendant care is a service delivery model within South Carolina's Community Choices (CC) Waiver, the state's primary Section 1915(c) Home and Community-Based Services program administered by SCDHHS through regional Community Long Term Care (CLTC) offices.

To use this model, the participant must first meet the standard CC Waiver eligibility requirements: a nursing facility level of care (NFLOC) determination and financial qualification under South Carolina's strict income-cap rules (gross monthly income at or below $2,982 for 2026, countable assets at or below $2,000 for a single applicant).

Once enrolled in the waiver, the participant requests self-directed attendant care during their service plan development with their CLTC case manager. The case manager authorizes a specific number of weekly care hours based on the clinical assessment (SC DHHS Form 1718). Those hours become the participant's budget — they decide how to allocate them across their chosen workers.

The critical structural piece is the fiscal intermediary. Self-directed participants don't handle payroll, taxes, or workers' compensation directly. Instead, SCDHHS contracts with a fiscal intermediary organization that serves as the employer of record for the participant's chosen caregivers. The fiscal intermediary handles:

• Federal and state payroll tax withholding and filing
• Workers' compensation coverage
• Background check coordination through SLED (South Carolina Law Enforcement Division)
• Timesheet processing and direct deposit payments
• Compliance documentation for Medicaid audit requirements

The participant manages the day-to-day relationship — scheduling shifts, defining tasks, and supervising quality — while the fiscal intermediary manages the back-office employment obligations.

Who Can You Hire as a Self-Directed Caregiver?

This is where self-direction gets powerful for families. Under the CC Waiver's self-directed pathway, the participant can hire qualified family members and other workers the waiver permits:

• Eligible caregivers — the waiver and fiscal intermediary determine which relatives and other workers may be hired.

Caregivers must complete the background checks required by the waiver and fiscal intermediary. For licensed home care providers, S.C. Code Ann. § 44-7-2910 requires fingerprint-based checks through SLED and the FBI; the fiscal intermediary coordinates the applicable check. Workers who appear on the South Carolina Nurse Aide Registry abuse/neglect finding list or the OIG Exclusion List are disqualified.

Eligibility and conflict-of-interest restrictions are program-specific, so confirm that a proposed caregiver is permitted with the CLTC case manager and fiscal intermediary before hiring.

Setting Up a Caregiver Agreement That Protects Medicaid Eligibility

Paying a family member for caregiving through self-directed attendant care is processed through the fiscal intermediary as a waiver service rather than as a private-pay transfer. Follow the program's payroll and service-record requirements.

However, families should still maintain a written caregiver agreement that documents:

• The specific personal care tasks being performed (bathing, dressing, toileting, meal preparation, transfers)
• The authorized weekly hours from the service plan
• The hourly rate set by the fiscal intermediary (based on SCDHHS reimbursement rates)
• Start date and signatures from both parties

This documentation matters if SCDHHS audits the case or if the participant's eligibility is reviewed during the annual re-evaluation. A clear paper trail showing that payments match authorized service plan hours helps demonstrate that the arrangement follows the approved waiver service plan.

Practical Steps to Get Started

If your parent is already on the Community Choices Waiver, request self-directed attendant care during the next service plan review with the CLTC case manager. If your parent is on the interest list, ask about self-direction when a waiver slot is offered. If your parent is newly enrolling, ask about self-direction during the initial service plan development.

The CLTC case manager will connect you with the contracted fiscal intermediary. The timing for background checks and payroll setup depends on the waiver and fiscal intermediary; ask when the first paid shift can begin.

For families still navigating the CC Waiver application — or trying to understand how self-directed care fits alongside the financial eligibility rules, Miller Trust requirements, and estate recovery protections — the South Carolina Home Care Coordination Guide walks through the full waiver enrollment process and includes a caregiver agreement worksheet designed for exactly this situation.

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