How to Decide: Agency Care or Self-Directed Care


If you are in a Medicaid waiver or a Home and Community Based Care program, the state will provide you with a caregiver (also called a “home aide” or “home attendant). But you have a big choice to make!

πŸŽ€ If you want, you can select an agency and that agency will send a caregiver to your house.

πŸŽ€ Or if you want, you can sign up for self-directed care. With self-directed care, you get to choose and hire your own caregiver, and the state pays the salary.

Big decision! Here’s some pros and cons each way:

Agency Care

πŸŽ€ Advantage: Less paperwork

πŸŽ€ Advantage: Less bureaucratic confusions and complications

πŸŽ€ Disadvantage: In some states you will get less caregiver hours if you go through an agency. You may only get half the hours.

πŸŽ€ Disadvantage: The agency does not guarantee to cover all your shifts. Sometimes they can’t find someone to work and so you won’t get a caregiver until they find one, or you may have days when no caregiver arrives.

πŸŽ€ Disadvantage: Agency may have rules that do not allow the caregiver to use their car or to drive you places.

πŸŽ€ Disadvantage: Some agencies will not allow the caregiver to handle your money. This means they cannot shop unless you are with them.

πŸŽ€ Disadvantage: This is a bad combination. If they cannot drive you places and they cannot shop without you there, shopping may be impossible.

πŸŽ€ Disadvantage: If you have special needs, such as not wearing perfume, the agency may not make these arrangements and the caregiver may not agree.

πŸŽ€ Disadvantage: You can’t control who they send. You can’t pick someone you like.

πŸŽ€ Some agencies only pay their workers $7-$8 per hour and it is hard to find anyone who is good or willing to keep a job at this pay rate

Self Directed Care

πŸŽ€ Advantage: Pick your own attendant. Choose whoever you want. (exception: In most states it cannot be your spouse).

πŸŽ€ Advantage: You can find someone you really like and feel comfortable with.

πŸŽ€ Advantage: You can find someone who meets your needs. For example, if you need someone who owns a car, you can be sure to only hire someone who owns a car. If you want someone who can shop for you, you can be sure to only hire someone that you trust to give your grocery money to.

πŸŽ€ Advantage: In some states, your caregiver will get a higher salary. In some states, you can help decide the salary.

πŸŽ€ Advantage/Disadvantage: You supervise the person and you are the “boss.” Maybe you like this, maybe you don’t.

πŸŽ€ Advantage: If you choose your own caregiver, you have the option to arrange a live-in caregiver if you want to. There are a lot of different advantages to this. For example, your caregiver may not have to pay taxes, or may be able to get free rent, or you may get extra help with your utility bills: How to Get Extra Help if You Have a Live-In Caregiver

πŸŽ€ Advantage: As soon as you are approved, you can begin getting assistance. You do not have to wait for an agency to place someone. For example, if the date of your Medicaid eligibility is in January, but the paperwork is not all processed and in place til March, you may be able to start tracking caregiver hours in January, and then submit three months of timesheets at once. This may vary by state.

πŸŽ€ Disadvantage: Takes time and energy to screen and select attendants

πŸŽ€ Disadvantage: More paperwork and timesheets to manage

πŸŽ€ Disadvantage: You will need to take responsibility for the paperwork, or find a friend or family member who is willing to take on this role. Most of the paperwork is in the first few months. Once you figure out the system, it gets a lot easier. You will have a caseworker who can answer questions and help guide you through the process.

πŸŽ€ Disadvantage: It can be work to find a caregiver. If your caregiver quits or does not show up for work, you can be left without help.

πŸŽ€ Disadvantage: The caregiver you chose must pass a background check for felonies or abuse crimes. (Other types of convictions may not be a problem).

πŸŽ€ Disadvantage: It takes time to complete the paperwork and do the screening to hire a new caregiver. The first paycheck may not come for several weeks or longer.

πŸŽ€ Disadvantage: It is common for people to run into problems with timesheets and payment, especially at the beginning. You may have to work directly with the payroll company to work everything out and resolve problems so your caregivers get paid. This can be a headache.

Learn More

There are a bunch of other little things it might help you to know if you are in this program: How to Get Extra Help if You Are in a Medicaid Waiver Program

If you decide to select your own caregiver: How to Find Wonderful Housemates & Caregivers

What Works For You?

I use an agency, but I have family friends that I wanted to be my attendants. We arranged for my family friends to get hired by that agency so they could provide my care. Now my family is much less stressed and that makes me feel less like a burden. I feel like I have much more support with getting all the services they offer. – Teri

I hired my brother. He was already taking care of me every day anyway! But it was not a good situation. He was only taking care of me short-term because it was an emergency. He didn’t know what to do because he needed to get a job but then there would be no one to help me. After I got in a waiver program, he was able to be paid to be my attendant. I got to keep the caregiver who I like and trust and he got the job of helping me, which is a job he likes. – Jasmine

It is not really a choice for me. Not everyone can manage their caregiver’s hours and back-up workers in case their worker is ill. I would not be able to hire my own workers. I have tried before and had bad experiences with the workers I chose.Β  It took a while, but the agencies I have now are able to work with me. I am spoiled by the agency. I would have to settle for whomever I hired if I went with an independent worker. – SXR

One negative about Home Services is conflict resolution. If you hire your own attendants, there is no third party to help resolve conflicts at home like there might be through an agency. The reality is the outcome of a resolution may consistently fall more into the favor of the worker instead of the person with disabilities. -SN

Learn More

How to Get a Caregiver or Home Attendant

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