Can Medicaid Pay You to Care for Your Parent or Spouse? The Federal Rules, and Ten States Read Closely

The question comes to me in two forms. "I quit my job to take care of my mother. Is there any way to get paid for this?" And, from a spouse, "I do everything an aide would do. Why can't Medicaid pay me?" The answers are different, and the difference is in federal rules that most state websites never show you.

I'm an occupational therapist, and I've worked in home health. I'm not a Medicaid caseworker or a lawyer. What I can do is show you the rules in their own words, explain the four kinds of Medicaid program that pay family caregivers, and tell you what ten states' own pages say, so that when you call your state you know what to ask for.

A note on labels. A federal rule is a regulation or statute, and I'll cite the paragraph. CMS guidance is the manual CMS gives states for writing waivers. A state rule or page is that state's code, policy manual or official website, and I'll name it. KFF is a nonprofit that surveys state Medicaid programs; where I use its numbers I'll say so. Anything labeled my experience or my suggestion is just that.

The Short Answer Depends on Who You Are to the Person

Before the state matters, your relationship matters. Federal Medicaid law sorts caregivers into two bins, and your bin decides how hard this is.

• Adult child, sibling, grandchild, friend, other relative. No federal rule stands in your way. Every one of the 48 states that answered KFF's 2024 survey pays family caregivers through at least one home care program. The state's program rules and waiting lists are your obstacles, not Washington.
• Spouse, or the parent of a minor child. Federal law treats you as a "legally responsible relative" (the words vary; more below). Regular state-plan personal care cannot pay you. A waiver can, if your state chose to allow it, and only for care beyond what a spouse or parent ordinarily provides; a 1915(j) or 1915(k) self-direction option can, if the state elected it, with no extraordinary-care test in the statute's text. KFF counts 40 states that allow it through waivers and six through the state plan.
• Parent of an adult child. This is the one that surprises people. CMS's own guidance says legally responsible individuals "do not include the parent of an adult beneficiary (including a parent who also may be a legal guardian)." You are in the first bin, with one catch: many states bar the person who directs the care (a representative, guardian or power of attorney) from also being the paid worker.

The Federal Rules, in Their Own Words

State-plan personal care: the family exclusion

Medicaid's basic personal care benefit is defined at 42 CFR §440.167. Paragraph (a)(2) says the service must be:

Provided by an individual who is qualified to provide such services and who is not a member of the individual's family

And paragraph (b):

For purposes of this section, family member means a legally responsible relative.

That is the whole exclusion. It is narrower than it sounds. It does not say "relative." It says "legally responsible relative," which CMS's guidance and most states read as the spouse and the parent of a minor child, as defined in state law. An adult daughter is not a legally responsible relative. Note also the rule's first words: "Unless defined differently by a State agency for purposes of a waiver." The exclusion is for the state plan, and waivers are the way around it.

Waivers: a state option, with an extraordinary-care test

Section 1915(c) waivers are the programs most states use for home care. Medicaid.gov says "about 257 HCBS Waiver programs are active nationwide," and that "States choose the maximum number of people that will be served under a HCBS Waiver program." The waiver regulations I read, 42 CFR §§441.301 to 441.303, say nothing about paying relatives. That policy lives in the waiver application itself, in two items CMS calls C-2-d and C-2-e, and in the technical guide CMS gives states for filling them in. The guide I read is version 3.6 (January 2019); CMS has since issued a version 3.7, which I could not download, so these quotes are from 3.6.

On legally responsible individuals, the guide says:

CMS policy is that payments for personal care or similar services delivered by legally responsible individuals (as defined in state law but typically the parent of a minor child or a spouse) are not eligible for federal financial participation. Legally responsible individuals do not include the parent of an adult beneficiary (including a parent who also may be a legal guardian) or other types of relatives, except as provided in state law).

And then the door:

Through an HCBS waiver, a state may elect to make payment for personal care or similar services that are rendered by legally responsible individuals when such services are deemed extraordinary care so long as the state specifies satisfactory criteria for authorizing such payments.

With the test:

By extraordinary, CMS means care exceeding the range of activities that a legally responsible individual would ordinarily perform in the household on behalf of a person without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the participant and avoid institutionalization.

And the sentence to remember when a state says no: "In any case, providing for payments to legally responsible individuals is a state option, not a federal requirement."

For everyone else, item C-2-e covers "payment for the provision of any type of waiver service by a relative or legal guardian." The guide says "It is up to the state to decide whether to provide for either type of payment and, when such payments are made, to specify the circumstances when they are permitted," and gives examples of limits a state might set, such as paying "only to specified types of relatives (e.g., relatives who do not reside in the same household as the participant)." Whoever is paid "must meet the provider qualifications that apply to a service and there must be a properly executed provider agreement."

Waivers can also have waiting lists. 42 CFR §441.303(f)(6) lets a state limit the number of people served, and the Medicaid.gov line above says so in plain words. Being eligible for a waiver and being enrolled in it are two different things.

Self-directed personal assistance, 1915(j): the statute names relatives

Section 1915(j) of the Social Security Act, 42 U.S.C. §1396n(j), is a state-plan option for self-directed personal assistance. Its definition at §1396n(j)(4)(B) says:

At the election of the State— (i) a participant may choose to use any individual capable of providing the assigned tasks including legally liable relatives as paid providers of the services

The regulation, 42 CFR §441.450, defines the term:

Legally liable relatives means persons who have a duty under the provisions of State law to care for another person. Legally liable relatives may include any of the following: (1) The parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child. (2) Legally-assigned caretaker relatives. (3) A spouse.

Medicaid.gov's page on 1915(j) lists, among what a state may let enrollees do, "Hire legally liable relatives (such as parents or spouses)." The same rules give the participant the authority to recruit, hire, discharge, train, schedule and supervise workers (§441.450(b)), and let a state hand the participant cash to manage: "States have the option of disbursing cash prospectively to participants, or their representatives, as applicable, self-directing their PAS" (§441.454(a)). Medicaid.gov's page says participation "is voluntary," and the regulation lets a participant leave and return to agency care at any time (§441.456(a)).

Community First Choice, 1915(k): "including family members"

Community First Choice is the Affordable Care Act's attendant services option, 42 U.S.C. §1396n(k). The statute requires the services to be:

provided by an individual who is qualified to provide such services, including family members (as defined by the Secretary)

The regulations at 42 CFR §§441.500 to 441.590 give the enrollee the choice of an agency model or "a self-directed model with service budget," and allow direct cash: "States may disburse cash prospectively to individuals self-directing their Community First Choice services and supports" (§441.545(b)(2)). Medicaid.gov says the option "provides a 6 percentage point increase in Federal matching payments to States for service expenditures related to this option." It is a state plan option rather than a waiver, and a CMS training deck on home and community-based services lists among state plan requirements that "Generally, services must be available statewide," with statewideness among the things a 1915(c) waiver can waive. That is why a Community First Choice state tends not to have the waiting lists a waiver does.

Three phrases, one idea

You will meet "legally responsible relative" (§440.167), "legally liable relative" (§441.450) and "legally responsible individual" (the waiver guide). They are the same idea: a person state law obliges to care for another, typically a spouse or the parent of a minor. Who exactly is in that group is defined by your state's law, which is why the same federal rules produce different state answers.

The Four Doors, Side by Side

KFF's January 2025 brief on its 2024 survey of state home care programs puts numbers on how states have used these doors. In KFF's words: "All responding states allow payments to family and friends through one or more waiver programs, but fewer states allow payments to legally responsible relatives. Forty states allow payments to legally responsible relatives through waiver programs, and only six states allow payments to legally responsible relatives through the state plan. Payments to other family and friends are also less common through the state plan—allowed by only 22 states." Florida, Indiana and Utah did not respond. KFF also notes that "10 states have adopted programs known as structured family caregiving, in which family members are paid a per diem rate" through an agency rather than an hourly wage.

Ten States, Read From Their Own Pages

A fifty-state table would be guesswork, because the answer in each state depends on which of several programs the person is in. Instead, here are ten large states whose own rules or official pages I read. Where a page did not address a question, the cell says so. "Other relatives" means an adult child, sibling or similar relative who is not the person's spouse, representative or guardian.

I tried and could not read Massachusetts (its site refused every request), Minnesota (its policy pages would not load), Pennsylvania and Georgia (no page I reached answered the spouse question). They are not in the table for that reason, not because the answer is no.

What the ten pages say

Arizona. The AHCCCS Medical Policy Manual, chapter 1240-A, defines extraordinary care as "Care that exceeds the range of activities that a spouse or a legally responsible parent of a minor child would ordinarily perform in the household on behalf of the ALTCS member if the member did not have a disability or chronic illness, and which is necessary to assure the health and welfare of the member." For a member who elects a spouse as paid caregiver, "personal care, or similar services in excess of 40 hours in a seven-day period will not be authorized," and the case manager "shall, at least annually, record in the member's PCSP, the member's choice to have attendant care provided by the member's spouse as a paid caregiver." The member must also be told "that they have the choice of a provider of attendant care other than the member's spouse." The same chapter covers parents of minors under a Parents as Paid Caregivers model, and for both: "The spouse/parent shall be paid at a rate that does not exceed what would otherwise be paid to a non-spouse/parent caregiver providing a similar level of attendant care services."

California. In-Home Supportive Services is the biggest family-caregiver program in the country, and the state's hiring fact sheet is blunt: "As the employer, you can hire anyone who meets IHSS provider enrollment requirements and can meet your needs. This may be a family member, friend, or someone referred from the Public Authority Registry." Spouses and parents are handled by moving the case between funding streams. The state's paraphrased regulations say the Personal Care Services Program "is unavailable to individuals whose provider is their spouse or to minor individuals whose parent is the provider," while the IHSS Plus Option serves people who don't qualify for PCSP, and "Such recipients often include individuals where the spouse is the provider or minors when the parent is the provider." For children, All County Letter 23-106 (December 2023) implements AB 120, "which eliminated provider eligibility requirements for minor recipients," so a parent can be the paid provider; the letter tells counties to "ensure that minor recipients who wish to hire a parent are enrolled in CFCO, IPO, or IHSS-R," since parents remain barred in PCSP.

Florida. The state's Long-Term Care managed care contract (exhibit II-B, February 2025) says enrollees who choose the Participant Direction Option "may hire any individual who satisfies the minimum qualifications set forth in Section VII., Provider Network and Services, including but not limited to neighbors, family members, or friends. The Managed Care Plan shall not restrict an enrollees' choice of direct service worker(s)." The exhibit does not mention spouses. A representative "can neither be paid for services as a representative, nor be a direct service worker." Florida did not answer KFF's survey, so I have no second source on spouses; ask the plan.

Illinois. Two programs, two answers, which is the best illustration I found of why the state alone doesn't tell you. The Home Services Program customer handbook says "There are some situations where the person you choose may not be able to provide services. One example would be a legally responsible person: such as your spouse or a parent and guardian if you are under the age of 18." The Department on Aging's Community Care Program, for people 60 and over, says the opposite about spouses: "Any family member (including a spouse), a Power of Attorney, representative payee, legal guardian, friend or neighbor must meet qualifications, pass a background check, complete 24-hours of pre-service training, and be hired and supervised by an In-Home Services agency before serving as a paid caregiver."

Michigan. The Home Help page: "The caregiver must be at least 18 years old. The caregiver cannot be the client's spouse. The caregiver cannot be a parent caring for a minor child." The client handbook repeats both. Michigan's MI Choice waiver has its own rules, which I did not read.

New York. The Department of Health's CDPAP page says the personal assistant "can include a friend or family member, as long as they are not the Medicaid member's spouse, their designated representative or the parent of a CDPAP consumer under the age of 21." The regulation, 18 NYCRR §505.28, puts it as a rule with a condition: "A person legally responsible for the consumer's care and support, a consumer's spouse, or the consumer's designated representative shall not be the consumer directed personal assistant for that consumer; however, a consumer directed personal assistant may include any other adult relative of the consumer provided that the social services district or MMCO determines that the services provided by such relative are consistent with the consumer's plan of care and that the aggregate cost for such services does not exceed the aggregate costs for equivalent services provided by a non-relative personal assistant."

North Carolina. The CAP/DA policy (3K-2) is the plainest yes I found for spouses: "A spouse, parent, step-parent, child, sibling, or other relatives can be hired as the employee when a CAP/DA beneficiary is 18 years of age and older and the employee: a. Is at least 18 years of age; and b. Meets the qualifications based on need-based assessment." It adds that "A provider's external employment cannot interfere with or negatively affect the provision of services."

Ohio. Ohio Administrative Code 5160-44-32 (effective 2024) applies across the state's waivers, from the developmental disability waivers to MyCare Ohio and the Ohio Home Care Waiver. Its default: "a parent of a minor child, a spouse, and other legal representatives are not eligible to bill for medicaid reimbursable waiver services to an individual for whom they serve as legal representative." Its exception, paragraph (E): a parent of a minor or a spouse may provide waiver services only if "There is no other willing and able provider or direct care worker available" and the agency "has determined the health and safety needs of the individual can be ensured." Then "an individual may receive a maximum of forty hours per week of paid care from their spouse," the same cap applies to a minor's parents combined, the care "must meet extraordinary care requirements, as determined through prescribed form, ODM 10372 'Ohio Extraordinary Care Instrument'," and it "may not be provided for respite purposes." The Ohio Home Care Waiver handbook (July 2026) adds that once a parent or spouse is authorized, "Case Managers are required to contact you every 2-3 months to search for alternate able and willing providers."

Texas. The Consumer Directed Services FAQ (revised February 6, 2026) answers "Can I hire a family member to be my service provider?" with "It will depend on your program and other service requirements." Then the list that doesn't depend: "People who cannot be your employee include: The CDS employer. The spouse of the person receiving services, or the employer's spouse, except in Client Managed Personal Attendant Services (CMPAS). The designated representative or their spouse. The parent or legally authorized representative of a person receiving services who is under 18 years old."

Washington. The DSHS page "Becoming a Paid Caregiver": "Family members who provide care to a relative can become paid caregivers if the care recipient qualifies for Medicaid Long Term Services and Supports," with "35 hours of training" to "Complete your training within 120 days of hire." And on spouses: "Under Apple Health and the Long Term Services and Supports program, you cannot be paid to provide care for your spouse. However, there are programs in Washington that do allow spouses to be paid caregivers: Veteran Directed Care" and the "WA Cares Fund," which "will allow spouses to be paid caregivers if the person receiving care has earned WA Cares benefits and meets the required level of need."

What the ten have in common

Read together, the pages show the pattern the federal rules predict. Other relatives: yes nearly everywhere, with the person who directs the care usually barred from also being paid. Spouses and parents of minors: a state choice, and where the answer is yes it comes with an extraordinary-care test, a 40-hour cap, an agency or fiscal agent in the middle, and someone checking whether another worker could be found. None of the ten pages I read set the hourly rate on the page.

What It Pays

There is no national Medicaid wage for a family caregiver, and I'd be wary of any page that gives you one. What the rules do say is how the money is sized. In self-directed programs the state builds a service budget from the assessed need (42 CFR §441.470 for 1915(j); §441.545(b) for Community First Choice), and the enrollee spends it on workers. KFF counts 38 states that let enrollees set their caregivers' pay rates. Two of the ten states' rules cap a relative at what a non-relative would cost. Arizona: "The spouse/parent shall be paid at a rate that does not exceed what would otherwise be paid to a non-spouse/parent caregiver providing a similar level of attendant care services." New York: the "aggregate cost for such services does not exceed the aggregate costs for equivalent services provided by a non-relative personal assistant." For a sense of scale, the median hourly wage for home health and personal care aides, by state, is in our home health aide certification and pay article. Expect Medicaid family-caregiver rates to sit around those numbers, not above them.

Two practical points from my experience. Payment runs through a fiscal agent or an agency, with timesheets and, in most states now, electronic visit verification; it is a job with payroll, not a stipend in the mail. And the hours are the assessed hours, which are almost always fewer than the hours you actually spend. The pay helps. It does not replace a salary.

How to Find Your State's Program

My suggested order:

1. Confirm the person is on Medicaid, or could be. Family caregiver pay is a Medicaid long-term care benefit; the person you care for is the enrollee, not you. If they are on Medicare only, this door is closed, and our article on who pays for respite care covers what is open.
2. Ask their case manager or managed care plan one question: "Which of your programs let the enrollee hire a family member, and is there a waiting list?" Use the words "self-directed," "consumer-directed" or "participant-directed." Texas's FAQ, above, tells you who to ask: the service coordinator, case manager or fiscal agent.
3. Call the Area Agency on Aging or Aging and Disability Resource Center. The federal Eldercare Locator finds yours by zip code. They know the waiver names and the waiting lists.
4. Look up the state's waivers yourself. Medicaid.gov's State Waivers List shows every approved 1915(c) waiver and 1115 demonstration by state. Each waiver's name and target group tells you whether it fits (aged and disabled, developmental disabilities, brain injury and so on).
5. If you are a spouse or the parent of a minor, ask for the program's extraordinary-care rule by name. Arizona, Ohio and the CMS guide all use that phrase. If the program has no such provision, the answer is no in that program, and you move to the next one.

If the person is a veteran, the VA's Program of Comprehensive Assistance for Family Caregivers pays a stipend without any of this, and Veteran Directed Care lets a veteran hire family in states that otherwise bar spouses, as Washington's page says. Our VA home health aide program article covers the VA side. And if the hours you need are more than any program will fund, our piece on 24-hour home care costs shows what the gap looks like, and the caregiver burnout article covers the help that isn't money.

Frequently Asked Questions

Can I get paid by Medicaid to take care of my mother?

Often, yes, if she is on Medicaid and qualifies for home care. An adult child is not a legally responsible relative under the federal rules, so no federal rule stands in your way; your state's program rules decide. KFF's 2024 survey found that all 48 responding states pay family caregivers through at least one Medicaid home care program. The usual route is a self-directed or consumer-directed option, where your mother is the employer, you are her worker, and a fiscal agent handles payroll. Start with her state Medicaid agency or the local Area Agency on Aging.

Can Medicaid pay a spouse to be a caregiver?

Not through regular state-plan personal care: 42 CFR 440.167 bars payment to a legally responsible relative, and CMS's guidance names the spouse and the parent of a minor as the usual examples. States can pay a spouse through a waiver, where CMS requires an extraordinary-care test, or through a 1915(j) or 1915(k) self-direction option, where the statute leaves it to the state, but only if the state chose to. Of the ten states I read, Arizona, California, Illinois's Community Care Program, North Carolina and Ohio allow it in at least one program, several with a 40-hour-a-week cap; Michigan's Home Help, New York's CDPAP, Texas's CDS option, Washington's Apple Health long-term care and Illinois's Home Services Program do not.

Can a parent be paid to care for a disabled adult child?

The federal barrier is lower than most people think. CMS's waiver guide says legally responsible individuals do not include the parent of an adult beneficiary, even one who is also the guardian, so the extraordinary-care test for spouses and parents of minors does not apply to you. What applies is the state's rule on paying relatives and on paying a guardian or representative, and several states bar the person who directs the care from also being the paid worker. New York, for example, lets a parent be the assistant for a child 21 or older but not younger.

How much does Medicaid pay family caregivers?

There is no national Medicaid rate. In self-directed programs the state sets a budget from the assessed hours and either sets the hourly wage or lets the enrollee set it within the budget; KFF counts 38 states that let enrollees set caregiver pay rates. Arizona and New York, among the states I read, cap a relative's pay at what a non-relative would be paid for the same service. Ten states use a structured family caregiving model that pays a daily stipend through an agency instead of an hourly wage. Ask the program for its current rate before you plan around it.

How do I find the Medicaid program that pays family caregivers in my state?

Four places. The state Medicaid agency's long-term care or home and community-based services pages, searching for self-directed, consumer-directed or participant-directed services. The local Area Agency on Aging or Aging and Disability Resource Center, found through the Eldercare Locator. Medicaid.gov's State Waivers List, which shows every approved 1915(c) waiver by state. And the person's Medicaid case manager or managed care plan, who can say which programs they are eligible for and whether there is a waiting list.

Sources

Federal rules and statute (Cornell LII):

• 42 CFR §440.167, Personal care services
• 42 CFR §441.303, Supporting documentation required (waiver limits, (f)(6))
• 42 CFR §441.450, Self-directed PAS: basis, scope, and definitions
• 42 CFR §441.454, Use of cash
• 42 CFR §441.456, Voluntary disenrollment
• 42 CFR §441.470, Service budget elements
• 42 CFR §441.545, Community First Choice service models
• 42 U.S.C. §1396n, subsections (c), (j) and (k)

CMS and Medicaid.gov:

• Application for a §1915(c) Home and Community-Based Waiver: Instructions, Technical Guide and Review Criteria, Version 3.6 (January 2019), items C-2-d and C-2-e
• Medicaid.gov, Home and Community-Based Services 1915(c)
• Medicaid.gov, Self-Directed Personal Assistance Services 1915(j)
• Medicaid.gov, Community First Choice 1915(k)
• Medicaid.gov, Self-Directed Services
• Medicaid.gov, State Waivers List
• CMS, HCBS 101 presentation (state plan statewideness; what a 1915(c) waiver may waive)
• Eldercare Locator (Administration for Community Living)

State rules and pages:

• Arizona AHCCCS Medical Policy Manual, chapter 1240-A, Attendant Care
• California CDSS, IHSS: Finding, Interviewing, and Hiring a Provider
• California CDSS, All County Letter 23-106 (December 21, 2023)
• California CDSS, Paraphrased Regulations: In-Home Supportive Services
• Florida AHCA, Long-Term Care Program contract, Exhibit II-B (February 1, 2025)
• Illinois DHS, Home Services Program Customer Handbook
• Illinois Department on Aging, In-Home Care (hiring a family member)
• Michigan MDHHS, Home Help
• Michigan MDHHS, Home Help Program Client Handbook (Pub-1733)
• New York State Department of Health, Consumer Directed Personal Assistance Program
• New York, 18 NYCRR §505.28
• North Carolina Medicaid, Clinical Coverage Policy 3K-2, CAP/DA
• Ohio Administrative Code 5160-44-32
• Ohio Home Care Waiver Handbook (July 2026)
• Texas HHSC, Consumer Directed Services FAQ (revised February 6, 2026)
• Washington DSHS, Becoming a Paid Caregiver

Survey (cited as theirs):

• KFF, How do Medicaid Home Care Programs Support Family Caregivers? (January 13, 2025)