But here’s the good news: when you understand how Medicaid waivers for self-direction actually work, everything begins to change. These waivers give individuals and families real choice, control, and freedom in how care is delivered. They allow people to stay in their homes, hire caregivers they trust—often a family member or friend—and shape care around their lifestyle, not the other way around.
And that’s powerful.
At Ankota, we’ve had the privilege of working with agencies and providers who are passionate about delivering care that honors each person’s dignity and independence. We’ve also partnered with families who, once they understood the power of self-direction, completely transformed their loved one’s care experience.
In this article, I want to walk you through what these waivers are, who qualifies, how they work, and how the right software can take the stress out of managing them. Whether you're a provider looking to expand into self-directed services, a caregiver trying to understand your options, or just someone exploring this for the first time—my goal is to make this simple, clear, and actionable.
Let’s dive in.
A Medicaid waiver is basically a special permission that a state gets from the federal government. It allows them to customize Medicaid services for specific groups of people—like older adults, people with disabilities, or those needing long-term care at home.
Now, normally Medicaid has some pretty strict rules. But with a waiver, states can “waive” (hence the name) certain federal requirements so they can offer more flexible, personalized services—especially outside of institutions. That means instead of being forced into a nursing home or facility, folks can get the care they need right at home, in the community they love, and with people they trust.
Here are a few common types of waivers you’ll hear about:
1915(c) Home and Community-Based Services (HCBS) Waivers – These are the ones that let people receive long-term care outside of institutions, in their own homes or communities.
1915(b) Waivers – These allow states to use managed care models, where they work with networks of providers to deliver care more efficiently.
1115 Demonstration Waivers – These are more experimental and let states try out new ideas for improving Medicaid delivery.
But the one we’re focusing on today is the self-directed care waiver, often connected to 1915(j) or a state-specific variation.
This is where things get really exciting—because this waiver hands the reins to you, or your loved one, or the people you're supporting as an agency.
It lets people hire their own caregivers, set their own schedules, and build a care plan that actually fits their life—not just a checkbox on a form.
And yes, this can all sound like a lot—but that’s why I’m walking you through it. By the time you finish reading this, my goal is for you to feel more confident, informed, and ready to take the next step.
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Alright, so now that we’ve talked about what Medicaid waivers are, let’s dig into self-directed care—because this is where things start to get really empowering.
When I say self-directed care, what I’m really talking about is choice. It’s about giving individuals—not agencies, not institutions, not case managers—the ability to decide who provides their care, when it happens, and how it’s delivered.
Think of it like this: imagine being able to say, “I want my daughter to be my paid caregiver,” or “I’d prefer someone from my own community who speaks my language and understands my culture.” That’s what self-direction allows.
Instead of having services dictated by an agency’s schedule or a list of pre-approved providers, you get to be in charge. You—or someone you trust—can:
Hire and manage your own caregivers (even family or friends in many cases)
Create your own care plan, built around your real needs and daily life
Control your care budget, within the limits set by your waiver
Decide what services matter most to you, whether that’s help with bathing, preparing meals, or even using technology
I’ve seen people light up when they realize they have this kind of power. I once spoke with a mother whose teenage son has autism. With a self-directed waiver, she was able to bring in a behavior support coach who actually connected with him—and she coordinated everything around his school and therapy schedule. She told me, “For the first time, it feels like we’re not just managing care... we’re living our lives again.”
That’s what this is about. Self-direction isn’t just a program—it’s a shift in mindset. It says, “You know what’s best for you—and we’re here to help you do it your way.”
Of course, self-direction comes with responsibilities too. You’re managing schedules, timesheets, and sometimes even payroll. But that’s where tools like Ankota’s self-direction platform come in to help. (More on that soon.)
Bottom line? Self-directed care gives people the freedom and dignity they deserve. And it’s changing lives every day.
I’ll tell you this from experience: once families understand what self-direction really offers, they don’t want to go back. It’s not just about saving costs or filling out fewer forms—it’s about ownership, flexibility, and the ability to live life on your own terms.
Here are a few of the biggest reasons I hear time and again:
With self-direction, you get to choose who provides your care and how that care is delivered. You’re not assigned a rotating list of strangers—you decide who enters your home, who you trust, and who understands your needs. That’s a game changer.
Traditional agency models often force people to adjust their routines to fit into preset blocks of time. With self-direction, it’s the other way around. You build your care plan around your real life: school schedules, work hours, cultural practices, daily habits—whatever matters to you.
Let me say this plainly: people are happier with self-directed care. I’ve seen families go from feeling like they were barely coping to feeling confident, supported, and respected.
One of our clients told me: “It’s not just about care. It’s about living my life with dignity.”
And when you add the option to involve loved ones in care—as paid caregivers—it not only strengthens relationships but also provides economic relief for families that were already doing the work unpaid.
Now, does self-directed care come with more responsibility? Yes. You’re taking charge of schedules, possibly timesheets, and sometimes even payroll management. But don’t let that scare you. This is exactly where having the right technology makes all the difference.
And that’s why Ankota built a solution that supports both families and agencies, helping to manage the complexity so you can focus on what really matters: providing great care.
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By now, you might be thinking, “This sounds amazing—but am I (or my loved one) even eligible?”
That’s a great question—and the answer depends a little on where you live and which type of Medicaid waiver your state offers. But I’ll walk you through the general idea so you know what to expect.
Most self-directed programs start with a few basic eligibility requirements. Here's what they typically look for:
Self-direction is a Medicaid-funded service, so the first step is that you need to be enrolled in your state’s Medicaid program. If you're not enrolled yet, don't worry—you can still apply and go through the process.
That’s a fancy way of saying: you need regular help with things like bathing, dressing, eating, taking medication, or getting around. This is often confirmed through an assessment done by a case manager or nurse.
Some people can manage their own care planning, hiring, and schedules. Others may need a trusted representative—a family member or friend—who can step in and help oversee things. Either is perfectly okay.
So, to recap: if you’re on Medicaid, need long-term support, and are capable (with help if needed) of managing your care—you likely qualify for a self-directed care waiver.
Usually, once someone is deemed eligible, the next step is a care assessment. This is when a professional evaluates your needs, your daily routine, and your living situation. From there, you’ll work with a service coordinator or agency to develop a care plan and budget that fits your lifestyle.
Don’t let the word “assessment” intimidate you—it’s just a way to make sure you get the right amount of care and funding.
Once everything is approved, you can start hiring caregivers, setting schedules, and living your life on your own terms.
And remember, if you’re an agency helping people navigate this process, Ankota makes it easier—from enrollment workflows to documentation, budgeting, and caregiver management.
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Now here’s something important to understand—especially if you’re new to self-direction: while the participant is in charge of choosing caregivers and directing their own care, there’s still a lot of behind-the-scenes work that needs to happen. That’s where something called an FMSA comes in.
So, what’s an FMSA?
FMSA stands for Financial Management Services Agency. Think of them as your back-office support team for self-directed care. They’re not there to tell you how to run your care plan—but they handle the financial and administrative stuff, so you don’t have to stress about it.
Here’s what an FMSA typically helps with:
Processing caregiver payroll — They make sure your caregivers (even if they’re family) get paid on time and properly.
Filing employment taxes — Yes, even self-directed caregivers are employees, and the FMSA takes care of all the IRS stuff.
Budget management — They help track your care plan budget so you don’t overspend.
Staying compliant with Medicaid rules — They make sure everything is done by the book so your services don’t get interrupted.
If you're a participant or family member, you’ll usually get a list of approved FMSAs to choose from. Some states assign one; others let you pick. Either way, here are a few things I always recommend looking for:
Experience with Medicaid programs
Clear, transparent pricing
Easy-to-use tools or portals
Responsive support when you have questions
And if you're an agency looking to become an FMSA, Ankota’s platform can help you set up operations quickly and stay compliant every step of the way. We've worked with organizations across the country to modernize how they manage payroll, reporting, and Medicaid billing—all within one system.
At the end of the day, an FMSA is your partner in making sure the financial and compliance side of self-direction is solid—so you can focus on the care itself.
Next, let’s talk about how the right technology—especially the kind we’ve built at Ankota—makes all of this even easier.
That’s where Ankota comes in.
We’re not just a software company—we’re your partner in care innovation. Our platform was purpose-built for Medicaid-funded care, and we’ve helped agencies, FMSAs, and providers across the country launch, scale, and optimize self-direction programs.
Here’s why agencies and FMSAs trust Ankota:
✅ Built-in EVV that’s tailored for self-direction
✅ Integrated billing for Medicaid, MCOs, VA, and more
✅ Real-time compliance tracking and care plan management
✅ User-friendly portals for families and caregivers
✅ Supportive onboarding and dedicated success team
We understand the challenges you face—and we’ve designed our tools to help you stay compliant, efficient, and focused on delivering care that truly makes a difference.
Whether you’re:
A home care agency looking to expand into self-direction
An FMSA needing a more modern back-end system
Or a state partner trying to improve your waiver program delivery
We’re ready to help.
If you’re ready to simplify operations, improve outcomes, and support families with greater flexibility—Ankota is here to help you lead the way.
Let’s empower more families to live with dignity, independence, and choice.
Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact us.