Self-Directed Care New Hampshire: How to Get Paid as a Family Caregiver Through the CFI Waiver

What Self-Directed Care Actually Means

Most families assume that Medicaid home care means an agency sends a stranger to your parent's house. In New Hampshire, that's one option. The other — and the one most families don't hear about until months into the process — is self-directed care through the Choices for Independence (CFI) waiver.

Under the self-directed model, your parent becomes the employer. They choose who provides their care — a son, daughter, neighbor, friend, or anyone they trust — and that person gets paid through Medicaid waiver funding. The caregiver earns up to $20 per hour, with payroll taxes, workers' compensation, and background checks handled by a state-approved fiscal management agency.

This isn't informal family caregiving with a stipend. It's a structured employment arrangement where the caregiver has a defined schedule, documented tasks, and legal protections as an employee.

Who Can Be Hired

The eligibility rules for self-directed caregivers are straightforward:

• Must be 18 years or older
• Must pass a mandatory criminal background check
• Cannot be the participant's spouse without explicit approval from the DHHS Division of Long-Term Supports and Services (DLTSS)

That spousal restriction is the one families most commonly run into. Adult children, siblings, grandchildren, nieces, nephews, friends, and neighbors are all eligible without special approval. If your mother needs daily ADL assistance and her daughter is already providing it unpaid, the CFI waiver can formalize and compensate that arrangement.

How to Set It Up

Self-directed care isn't available as a standalone program — it operates within the CFI waiver. Your parent must first be enrolled in the waiver, which requires clearing both clinical eligibility (nursing facility level of care, two or more ADL deficits) and financial eligibility (gross monthly income under $2,982, assets under $8,500 after the He-W 856.07 disregard).

Once enrolled, the process works like this:

Step 1: Request the self-directed option. Tell the assigned Care Coordinator that your parent wants to use self-directed care rather than agency-provided services. This is a participant right, not a special exception.

Step 2: Select a caregiver. Identify the person your parent wants to hire. The coordinator will help initiate the background check and enrollment paperwork.

Step 3: Connect with the fiscal management agency. The fiscal agent acts as the employer of record for tax and payroll purposes. They handle federal and state payroll tax withholding, workers' compensation insurance, wage payments, and IRS reporting. Burd Home Health is one of the established fiscal management providers serving New Hampshire's CFI self-directed care participants.

Step 4: Establish the schedule. Working with the Care Coordinator, define the weekly schedule, specific ADL tasks, and total authorized hours. These are documented in the Plan of Care.

Step 5: Begin services. Once background checks clear and the fiscal agent completes enrollment, the caregiver starts working on the approved schedule and submits timesheets through the fiscal management system.

The Gateway Program

The Gateway Program is a related pathway that allows CFI participants to access self-directed services with additional flexibility in how they manage their care budget. Through Gateway, participants can have more control over how their authorized care dollars are spent — choosing between different service types based on their evolving needs.

Ask your Care Coordinator about Gateway eligibility if your parent wants maximum control over their care arrangement.

What the Caregiver Agreement Should Cover

Even though the fiscal management agency handles payroll, you should document the care arrangement in a written caregiver agreement. This serves two purposes: it clarifies expectations between family members, and it creates a paper trail showing that compensation is for documented services rendered — not a gift that could trigger Medicaid lookback penalties.

A basic caregiver agreement should specify:

• The specific ADL tasks the caregiver will perform
• The weekly schedule and total hours
• The hourly rate
• How schedule changes and time off are handled
• That the arrangement is contingent on continued CFI waiver enrollment

This agreement protects both the caregiver and the care recipient. It also demonstrates to Medicaid that payments are legitimate compensation for services, not disguised asset transfers.

Why Self-Directed Care Matters in New Hampshire Right Now

New Hampshire's home care staffing shortage is not theoretical. The Fitzmorris v. Weaver federal class-action lawsuit documented systematic failures in delivering authorized CFI care hours because agencies couldn't recruit and retain enough aides at Medicaid reimbursement rates.

Self-directed care doesn't depend on agency staffing levels. When your parent hires their own caregiver, they're drawing from a labor pool — family and personal networks — that agency-based care can't access. The aide who left an agency because the pay wasn't worth the commute might happily provide care to a neighbor down the road at $20 per hour with a flexible schedule.

For families already providing unpaid care — and in New Hampshire, that's a substantial number of adult children — self-directed care converts invisible labor into paid employment without changing who shows up to help every morning.

The Aging in Place in New Hampshire guide includes the complete self-directed care enrollment sequence, a caregiver agreement template, and the fiscal management service coordination checklist.

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