Caregiving Atlas

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Comparison

Paying a family caregiver through Medicaid: state-by-state mechanisms compared.

Almost every state lets some family members be paid by Medicaid to care for an eligible relative — but the vehicle, the eligible relationships, the hourly rate, and the cap on hours all vary. This table is a starting map. Final eligibility runs through your state Medicaid agency and the managed-care plan or fiscal intermediary that actually processes the timesheets. Six launch states have fully reviewed program details; the rest are registered with confidently-known program names and rate ranges flagged for editorial verification.

Six launch states · jump to a full guide

FloridaCaliforniaTexasNew YorkPennsylvaniaArizona

Self-directed Medicaid waiver / program

The named state mechanism that lets a Medicaid-eligible recipient select a family member as a paid caregiver. May be an HCBS §1915(c) waiver, a §1915(k) Community First Choice option, a §1115 demonstration, or — increasingly — managed-care plan participant-direction.

Six launch states · editorially verified

Florida

SMMC LTC Participant Direction Option

Statewide Managed Medicaid LTC self-directed option.

California

IHSS (In-Home Supportive Services)

Largest US program of its kind; spouses can be paid.

Texas

STAR+PLUS HCBS — Consumer Directed Services (CDS)

Through managed care organization.

New York

CDPAP

Consumer Directed Personal Assistance Program; rules in flux 2025-2026.

Pennsylvania

Community HealthChoices (CHC) participant-direction

Two financial-management service vendors statewide.

Arizona

ALTCS Member-Directed Option

Through Arizona Long Term Care System MCO.

Eligible caregiver relationships

Which family members may be paid. Federal Medicaid rules generally exclude spouses and legally responsible relatives from receiving payment, but state §1915(k) Community First Choice and several §1115 demonstrations have created exceptions. The list below is the typical case; specific programs apply additional eligibility rules.

Six launch states · editorially verified

Florida

Adult children, siblings; not spouses

Spouse exclusion under federal rule; verify state exceptions.

California

Most relatives including spouses

IHSS allows spouse payment under specific conditions.

Texas

Adult children, siblings; not spouses

Spouse exclusion under federal rule; verify state exceptions.

New York

Adult children, siblings; not spouses

Spouse exclusion under federal rule; verify state exceptions.

Pennsylvania

Adult children, siblings; not spouses

Spouse exclusion under federal rule; verify state exceptions.

Arizona

Adult children, siblings; not spouses

Spouse exclusion under federal rule; verify state exceptions.

Pay rate range (approximate)

Typical hourly pay for a family caregiver under the state mechanism. Rates vary by region within a state, by experience level, and by program tier; the numbers below are rough mid-2025 ranges. Verify current rates against the state Medicaid bulletin or MCO contract before relying on them.

Six launch states · editorially verified

Florida

~$13-17/hr

Varies by MCO and region.

California

~$17-22/hr

IHSS varies by county wage agreements.

Texas

~$11-15/hr

Low Medicaid HCBS rate ceiling.

New York

~$18-22/hr

Higher in NYC/downstate; lower upstate.

Pennsylvania

~$15-18/hr

Under CHC; varies by MCO.

Arizona

~$15-17/hr

ALTCS rate set by AHCCCS.

Typical hours/week cap

The upper bound on paid hours per week for one caregiver under the program. Real caps are set through an individualized assessment of the care recipient's needs; the figures below are the practical ceiling that most assessments respect.

Six launch states · editorially verified

Florida

Up to ~40 hrs/wk

Assessment-driven; varies by MCO.

California

Up to ~283 hrs/mo (~65/wk)

IHSS uses monthly hours; high-need cases higher.

Texas

Up to ~40 hrs/wk per worker

Assessment-driven through MCO.

New York

Up to ~40 hrs/wk per worker

Higher with multiple workers; OT rules apply.

Pennsylvania

Up to ~40 hrs/wk

Set by MCO assessment under CHC.

Arizona

Up to ~40 hrs/wk

Higher hours under high-needs assessment.

Tax treatment of caregiver pay

How the IRS and the state treat the wages. In nearly every participant-directed program the recipient (or a fiscal intermediary) is the W-2 employer, payroll taxes apply, and IRS Notice 2014-7 excludes 'difficulty-of-care payments' from federal income tax if the caregiver lives in the same home as the recipient.

Six launch states · editorially verified

Florida

W-2 via fiscal intermediary

Each MCO contracts an FMS vendor.

California

W-2 via county IHSS payroll

Notice 2014-7 applies when caregiver lives with recipient.

Texas

W-2 via fiscal intermediary or MCO

CDS uses Consumer Directed Services Agency.

New York

W-2 via fiscal intermediary

Single statewide FI under 2025 CDPAP transition.

Pennsylvania

W-2 via fiscal intermediary

Two FMS vendors statewide under CHC.

Arizona

W-2 via fiscal intermediary

Through ALTCS contractor.

Distinctive state notes

Editorial flavor — the most notable thing about how this state handles family-caregiver pay through Medicaid.

Six launch states · editorially verified

Florida

Self-direction folded into SMMC LTC — accessed through the chosen MCO.

California

IHSS is the largest US program; spouses can be paid (rare); county-level rate variation.

Texas

CDS rules limit relatives in same household — among the more restrictive.

New York

CDPAP went through statewide single fiscal-intermediary transition in 2025; rules still settling. [VERIFY]

Verification pending

Pennsylvania

Community HealthChoices unified the state's HCBS into MCO-run model statewide.

Arizona

ALTCS member-directed option administered by MCO — uniform statewide.

Notes

  1. Medicaid family-caregiver payment programs are administered either by the state Medicaid agency directly or by managed-care organizations operating under state contract. Day-to-day timesheet processing typically runs through a 'fiscal intermediary' or 'financial management services' vendor that handles payroll.
  2. Federal Medicaid generally prohibits paying spouses or legally responsible relatives to provide care — but §1915(k) Community First Choice and several §1115 demonstrations have created state-level exceptions. California, Minnesota, Oregon, and Washington are the most-cited states allowing spousal pay; rules vary in detail.
  3. IRS Notice 2014-7 excludes 'difficulty-of-care payments' from federal income tax when the caregiver lives in the same home as the Medicaid recipient. State income-tax treatment varies — most conforming states follow federal exclusion, but not all.
  4. Hourly rates and hours caps are subject to change with each state's biennial budget. The figures here should be treated as approximate; verify against the state Medicaid bulletin or MCO before relying on them.
  5. Eligibility for paid family-caregiver programs sits on top of underlying Medicaid LTC eligibility. The care recipient must qualify for Medicaid HCBS first; family pay is an option within that program, not a separate benefit.

Read the full state guides · six launch states

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