TL;DR: Self-direction exists in every state, but no two states run it the same way. Who sets a direct service worker's pay, who approves a shift before it is billed, whether the spending plan follows a state template, and how the FMS bills the payer all change at the state line, and often from one program to the next inside the same state. Nobody has published a side-by-side comparison, so we are building one. At Ankota, we run software for financial management services (FMS) providers and Electronic Visit Verification (EVV) across many states, and we are asking FMS teams to spend five minutes telling us how their state works. Everyone who takes part gets the full report.
We do Electronic Visit Verification in 18 states, and here is the most useful thing that work has taught us: when Medicaid is involved, every state is different. Not a little different. Different in ways that decide whether a visit gets paid. Two states can use the same EVV aggregator and still disagree on something as basic as how to identify the worker who showed up. Self-direction takes that variation and multiplies it, because families, not agencies, are the employers.
Self-direction works differently in every state because each state designs its own programs inside broad federal rules, and most states run several self-directed programs at once. The federal framework allows employer authority, budget authority, or both, and lets states choose among FMS models such as vendor fiscal/employer agent and agency with choice. Each state then fills in the details: pay rates, approval steps, EVV requirements, spending plan formats and billing. At Ankota, we see the result directly, because the same software has to fit a California self-determination FMS and a Missouri consumer-directed vendor.
The scale is bigger than most people realize. According to MACPAC's June 2025 report on self-direction, self-direction is available in all 50 states and the District of Columbia, with more than 1.5 million people enrolled in 2023. That same report notes that 44 states had at least one program with budget authority, while employer authority was even more common. So "self-direction" is less one program than a family of them, all sharing a name. (If you are newer to the vocabulary, our guide to understanding self-direction and FMS covers the basics, and CMS's self-directed services page lays out the federal structure.)
The part that surprises people is how much variation lives inside a single state. A state might run self-direction through its developmental disability waiver, its aging and physical disability waiver, a managed care plan, and a state plan personal care option, each with its own rules. That is why the first thing we ask an FMS is not "what state are you in?" but "which programs do you serve?"
EVV teaches us that states differ even on the details that look universal. Every EVV system has to identify the worker, the client, the service, the time and the location, but states disagree on how to fill in each of those fields. Missouri, for example, requires each worker's Family Care Safety Registry ID, while most other states identify workers with a combination of their name and some digits of their Social Security number. Same federal mandate, different data, different rejections if you get it wrong.
When we bring on a new state for EVV, we assume nothing carries over, even when the aggregator is one we already know well. Missouri is Sandata, and plenty of other states are Sandata, but Missouri wants the Family Care Safety Registry ID for every worker. If your software is built around the name-plus-Social-Security-digits pattern, every one of those visits is going to bounce. That's the lesson we keep relearning: the aggregator is the pipe, but the state decides what goes through it.
Self-direction layers its own questions on top. Some states require EVV for self-directed services through a state aggregator. Some let the FMS choose its own EVV system. Some exempt certain workers, such as family members who live with the participant. If you want the mechanics of how aggregators fit in, our article on EVV aggregators walks through them.
It depends on the state, and the two models could hardly be further apart. In California's Self-Determination Program, the family sets the pay rate for each direct service worker, and the FMS then adds its burden rate on top to cover employer costs such as workers' compensation, payroll taxes and insurance. In Missouri's Consumer Directed Services (CDS) program, the reimbursement rate is fixed by MO HealthNet, so pay is set the traditional way, with a starting rate close to minimum wage that grows with longevity and performance.
Those two approaches change almost everything downstream. In California, the budget is the constraint, so the family's real question is "how many hours can we afford at the rate we chose?" That is why the California spending plan tracks position against budget for the month and the year to date, which we cover in detail in our article on California Self-Determination Program spending plans. In Missouri, the rate is the constraint, so the questions look more like a home care agency's: how do we recruit at this rate, how do we reward the attendants who stay, and how do we keep every visit clean enough to get paid.
MACPAC found the same split nationally. Some states set minimum and maximum wages for self-directed services to simplify budgeting, while others let families set wages individually. Neither is wrong. But software that assumes one model will feel clumsy, or simply broken, to an FMS that lives in the other.
Beyond pay rates, FMS practices tend to differ in five places: what the FMS processes, what the family must approve, who can fix a shift, how the spending plan is reported, and how the payer is billed. Each of those decisions shapes daily work for the FMS team. Here is where we see the biggest differences.
What comes through the door. Some FMS providers process only hours from direct service workers. Others handle only invoices from vendors, such as a camp, a transportation provider or a piece of equipment. Many do both, and an FMS that handles both has two very different approval and payment flows running side by side.
What the family signs off on. In some programs, the family or employer of record approves every visit and every invoice before anything is billed. In others, only invoices need approval, or approval is not required at all. The same goes for the FMS's own fees. In some places the family reviews and approves them, in others they are simply disclosed, and in others the state sets them and the family never sees a number.
Who can fix a shift. When a worker forgets to clock out or misses a clock-in, someone has to correct it. In some states only FMS staff can touch a visit. In others the worker can correct their own time, or the family can adjust it as part of approving the timesheet. Most states land on some combination, and it is one of the places where EVV rigor and practical simplicity pull hardest against each other.
How the spending plan is reported. A few states publish a mandatory template that every FMS must follow. Most leave the format to the FMS, and some let each regional entity decide. That is a quiet but real cost, because an FMS serving several regions may maintain several versions of what is supposed to be one report.
How the payer gets billed. Some states take standard claims. Others require a state-specific portal or a custom file format, and some FMS teams do both depending on the payer. There is also the support system around the family. Many states have a person who helps families plan and use their budget well, but they call that role an independent facilitator, a support broker, a consultant, a case manager or a counselor, and whether a family must use one varies too.
Tip
If you run an FMS in more than one state, write these five answers down for each program you serve. It takes ten minutes, and it becomes the checklist you hold up against any software demo, including ours.
FMS software demos miss the mark because the vendor shows its own state's workflow, and the FMS team watching knows exactly how their program works. The moment a demo features a spending plan report the state does not require, or an approval step the program does not use, the audience stops seeing their operation on screen. At Ankota, we have learned to ask how a program runs before we show anything.
What we find as we go into a demo is that the group we're talking to knows exactly how they do FMS. They live it every day. The risk is on our side: if we walk in and show them the California burden rate setup when they run a Missouri-style program with fixed reimbursement, we've spent twenty minutes on something that isn't relevant to them. So now we try to learn their rules first, and only then show the parts of the software that match.
That experience is a big part of why we built our self-direction software to be configurable rather than state-specific. Home screens, family permissions, approval rules and report formats need to bend to the program, not the other way around. We wrote more about which features matter in our piece on fiscal intermediary software for FMS teams.
You can get the report by taking our five-minute survey on how self-direction works in your state. It covers the differences described above, from what your FMS processes and what families approve to EVV, spending plans, fees, billing and the support roles around the family. Everyone who completes it gets the full state-by-state comparison when it publishes, and there is no sales call attached.
A few things we promised when we built it, and that we are repeating here. Answers are reported in aggregate. No company is named unless you check a box giving us permission. Every question about state rules includes a "Not sure" option, because the person who runs billing is not always the person who knows what the state mandates, and a partial answer is still useful. Your email address is asked at the very end, and only so we know where to send the report.
Take the five-minute survey: How self-direction actually works in your state
The more states and programs that respond, the more useful the report becomes for everyone, including the FMS teams who are quietly wondering whether their state's way of doing things is normal. We suspect the honest answer is that there is no normal. We would like to prove it with data.
Ankota's self-direction FMS software supports fiscal intermediaries across different programs and states, handling direct service worker visits and vendor invoices, family approval, EVV, spending plans and billing, with the rules configured to match your program. If you would like to see how it fits the way your state runs self-direction, contact Ankota and tell us how you do it first. And if you have five minutes, take the survey so the report includes your state.
Each state designs its own self-directed programs inside a broad federal framework, choosing its FMS model, pay rate approach, approval rules, EVV requirements and billing method. Most states also run several self-direction programs at once, such as an I/DD waiver, an aging and physical disability waiver and a managed care option, and each can follow different rules.
Who sets the pay rate for a direct service worker in self-direction?It depends on the program. In California's Self-Determination Program, the family sets the worker's pay rate and the FMS adds a burden rate for workers' compensation, payroll taxes and insurance. In Missouri's Consumer Directed Services program, MO HealthNet fixes the reimbursement rate, so pay follows a more traditional ladder that starts near minimum wage and rises with longevity and performance.
Is EVV required for self-directed services?Federal law requires EVV for Medicaid personal care and home health services, including many that are self-directed, but states implement it differently. Some route self-directed visits through a state aggregator, some let the FMS choose its own EVV system, and some exempt certain workers, such as family members who live with the participant.
Does every state require a standard spending plan format?No. A few states publish a mandatory spending plan template, but most let each fiscal intermediary present the information in its own format, and in some states it varies by program or by regional entity. California, for example, expects the spending plan to show position against budget for the month and the year to date.
What is an independent facilitator or support broker?It is the person who helps a self-directing family plan services and make good use of their budget. States use different names for the role, including independent facilitator, support broker, consultant, case manager and counselor, and in some states using one is required while in others it is optional.
What do I get for completing the FMS state practices survey?Everyone who completes the five-minute survey receives the full state-by-state comparison of how FMS and self-direction programs operate. Answers are reported in aggregate, no company is named without permission, and there is no sales call attached.
Ankota's mission is to enable the Heroes who keep older and disabled people living at home to focus on care because we take care of the tech. If you need software for home care, EVV, I/DD Services, Self-Direction FMS, Adult Day Care centers, or Caregiver Recruiting, please Contact Ankota. And if you're ready to see how the most innovative agencies are using AI to empower their caregivers and automate the rest, meet your new companion at www.kota.care.