Self-Direction and FMS in Missouri

All states: self-direction map

Missouri self-direction at a glance

Last verified against state sources: 2026-10-13.

Which Medicaid programs in Missouri offer self-direction?

Missouri offers self-direction through two separate systems run by different state departments. Consumer Directed Services (CDS) serves adults with physical disabilities, through state plan personal care and the Independent Living Waiver. Self-Directed Supports (SDS) serves people with intellectual and developmental disabilities in the Division of Developmental Disabilities (DD) waivers. In all of them the participant, or someone acting for the participant, is the employer of the workers.

• Consumer Directed Services (CDS), state plan personal care: serves adults 18 and older with a physical disability who meet nursing facility level of care, can direct their own care and live independently. The Department of Health and Senior Services, Division of Senior and Disability Services (DSDS) authorizes services, the MO HealthNet Division pays, and Missouri Medicaid Audit and Compliance (MMAC) enrolls and monitors CDS providers. The participant has employer authority: the participant hires, trains, supervises and directs the attendant. We did not find an individual budget described for CDS.
• Independent Living Waiver (ILW): a 1915(c) waiver for adults 18 to 64 with a physical disability who meet nursing facility level of care and can self-direct. A participant may stay after 65 while able and willing to self-direct. DSDS operates the waiver and the MO HealthNet Division administers it. It gives personal assistance beyond the state plan limit, and it is the route for people who name a designee to help direct their care. The participant has employer authority. We did not find an individual budget described for the waiver.
• Self-Directed Supports (SDS) in the DD waivers: serves people with intellectual and developmental disabilities who are enrolled in a DD waiver and live in their own home or with family, including children. The Department of Mental Health (DMH), Division of Developmental Disabilities runs it. The individual has both employer authority and budget authority under state rule 9 CSR 45-3.080.

Employer authority means the participant recruits, hires, trains, manages and can dismiss the workers. Budget authority means the participant also controls a yearly budget allocation. DMH lists four DD waivers: Comprehensive, Community Support, Partnership for Hope, and Missouri Children with Developmental Disabilities. The rule says each waiver sets which services can be self-directed. We did not confirm that list for each waiver, so ask the support coordinator which services apply.

In state plan CDS, services are authorized in 15-minute units, and the total monthly CDS payment for a participant may not exceed 60 percent of the average statewide monthly nursing facility cost. Independent Living Waiver participants use up their monthly state plan CDS units before waiver units.

Who handles financial management services (FMS) in Missouri?

It depends on the system. In CDS and the Independent Living Waiver there is no single state FMS vendor: the participant chooses an enrolled CDS provider, and that provider does the payroll and tax work. In DD Self-Directed Supports the state uses one FMS contractor, Acumen (Acumen Fiscal Agent, LLC). In both systems the participant, not the vendor, is the legal employer.

This is a fiscal/employer agent model. The agent handles the paperwork side of being an employer, such as running payroll, withholding and filing taxes, and paying the workers, while the participant stays the employer of record.

• CDS (state plan): state law calls the CDS provider a vendor and calls its payroll role fiscal conduit services. The provider receives the Medicaid payment on the participant's behalf, sends pay directly to the attendant, and files payroll and employment taxes under the participant's tax ID. The MO HealthNet Personal Care Provider Manual says the attendant is the employee of the consumer and never of the provider, the department or the State of Missouri.
• Independent Living Waiver: Financial Management Services is its own monthly billable service. It is provided by enrolled CDS personal care providers that have filed a Financial Management Services Addendum with MMAC. The waiver manual says participants remain the employers of record.
• DD Self-Directed Supports: the individual, or a designated representative, guardian or parent of a minor, is the employer and holds the Federal Employer Identification Number. Acumen acts as the employer's agent for payroll, taxes and workers compensation requirements and pays the employees. Participants do not choose among FMS vendors. Support brokers are also available.

We did not find a public state list of enrolled CDS providers. To find one, ask DSDS or MMAC. State law holds a CDS vendor liable to the consumer for garnishments caused by late tax payments and sets a $1,000 penalty for each late payment occurrence.

Who can be a paid caregiver under self-direction in Missouri?

Family members can be paid in both systems, with limits. In CDS and the Independent Living Waiver the paid attendant cannot be the participant's spouse or legal guardian. In DD Self-Directed Supports the employer cannot hire a spouse, a parent or stepparent of a person under 18, a legal guardian or the designated representative.

• CDS (state plan): a family member may be the paid attendant if that person is not legally responsible for the participant, which rules out a spouse or guardian. The attendant also cannot be a current CDS participant or have prior Medicaid fraud involvement. The same manual says agency model personal care may not be provided by a family member at all, so the rule differs between the two models.
• Independent Living Waiver: attendant rules point back to the Personal Care manual, so the same spouse and guardian limits apply.
• DD Self-Directed Supports: family members who are not on the excluded list may be hired for personal assistance only, and cannot be paid for more than 40 hours a week.

Hours and pay have limits in the DD waivers. Time worked over 40 hours a week cannot be billed to MO HealthNet. Those hours are the employer's responsibility and must still be paid through the FMS, and employers may not add to wages outside the FMS agreement. For CDS, the General Assembly sets the statewide reimbursement rate. We did not find a published attendant wage floor or a weekly hour cap for CDS attendants.

Does EVV apply to self-directed workers in Missouri?

Yes. Electronic visit verification (EVV) applies to self-directed personal care in both systems. In CDS, each CDS provider picks an EVV system that sends data to the state's EVV Aggregator Solution, and claims with no matching visit have been denied for dates of service on or after April 1, 2026. In DD Self-Directed Supports, personal assistants record shifts in the DCI Mobile app, with resources from Acumen.

• CDS (state plan): the provider must collect EVV records and check that they are accurate, and the consumer must allow EVV use and monitor it. MO HealthNet's claims validation notice covers DSDS-authorized consumer directed services billed by provider types 26 and 28.
• Independent Living Waiver: the FMS provider collects and processes the attendants' EVV records. The participant choice statement includes an acknowledgment that providers and participants may not opt out of EVV.
• DD Self-Directed Supports: DMH's EVV page says EVV is required for all Medicaid-funded personal care, agency and self-directed, and that all SDS participants must follow it. Acumen's employee handbook lists the DCI Mobile App, Phone-In EVV and a FOB device as EVV-compliant ways to submit time.
• Live-in caregivers: Missouri does not exclude live-in caregivers from EVV. The state's EVV setup page says there is no such exclusion.

One point could not be confirmed. We did not find a statement that a DD self-directed employee's pay is held when time is not captured by an EVV-compliant method. The Acumen handbook we read still describes web time entry and, with prior approval, paper time sheets, and we could not confirm how current it is. Ask Acumen or DMH at GeneralSDS@dmh.mo.gov. General EVV questions go to Ask.EVV@dss.mo.gov.

What is changing next for self-direction in Missouri?

The main item is the FMS contract for DD Self-Directed Supports. DMH says its Request for Proposal for contracted fiscal management services has not concluded, that an award will be announced when it is final, and that the contract with Acumen has been extended in the meantime. No award and no transition date have been published, so Acumen remains the FMS today.

DMH posts these updates on its Self-Directed Supports page. The same page says support coordinators can enter SDS budgets for October 1, 2026 through January 31, 2027. We did not find a published end date for the contract extension.

Other items to watch, none of them final:

• Self-Directed Supports rule: in February 2026 DMH asked for feedback on proposed amendments to 9 CSR 45-3.080. The draft would widen the hiring exclusion from legal guardian to anyone with court or Social Security recognized legal responsibility (such as a conservator, power of attorney or payee), allow personal assistant support during a hospital stay, and tie the SDS budget to the service rate set by appropriations. DMH says none of the proposed changes are in effect and that it is reviewing further changes and will ask for feedback again.
• EVV claims checks for DD waiver personal care: MO HealthNet announced that claims validation would extend to DMH DD and Brain Injury Waiver personal care (provider type 85), with a tentative date in fall 2026. We did not find a notice confirming that it started or was delayed, and we did not find a statement on whether self-directed personal assistant claims are included.
• Independent Living Waiver: the Department of Social Services posted a public notice of a waiver amendment application on February 24, 2026. We could not read the amendment, so we cannot say what it changes.

Missouri self-direction sources

• Missouri DHSS: HCBS Manual section 3.25, Consumer Directed Services
• MO HealthNet: Personal Care Provider Manual (published August 10, 2026)
• MO HealthNet: Independent Living Waiver Provider Manual
• Revised Statutes of Missouri, section 208.900 (CDS definitions)
• Revised Statutes of Missouri, section 208.909 (CDS consumer and vendor duties)
• Missouri DMH Division of Developmental Disabilities: Self-Directed Supports
• Missouri Code of State Regulations: 9 CSR 45-3 (includes 45-3.080, Self-Directed Supports)
• Missouri DMH: Electronic Visit Verification for Self-Directed Supports
• MO HealthNet: EVV claims validation hard launch begins April 1, 2026

Related reading

• Missouri EVV April 2026: What Changed and How to Stay Paid
• Self-Directed Medicaid Home Care Services in 2026
• Understanding Self-Direction and FMS
• Self-Direction Fiscal Intermediary: A Guide for Participant-Directed Care
• Self-direction in every state (map)
• Missouri EVV requirements

Page history

• October 13, 2026: Page rewritten and checked against state sources.

This page is a reference, not legal advice. State rules change, so confirm details with the state before you act on them.

Ankota provides software for FMS organizations and agencies that support self-direction. If you would like to talk through your program, contact Ankota or read more about Ankota's self-direction and FMS software.