Medicaid Structured Family Caregiving Program: Paying Loved Ones as Caregivers

Structured Family Caregiving (SFC) is a Medicaid-funded benefit that supports primary unpaid caregivers of persons who are generally aged, disabled, or have Alzheimer’s disease or a related dementia. The caregiver lives with the care recipient and receives payment for providing supervision, personal care assistance, and homemaker services. Caregivers are provided with education and training based on current and anticipated needs of their loved one, coaching (including emotional support), a fill-in caregiver, and / or respite care.

As the name, “Structured Family Caregiver” implies, the caregiver is often a family member, and sometimes, even a spouse. The caregiver, however, does not have to be related to the care recipient. Caregivers are generally already serving as the live-in caregiver, either in their home or the home of the care recipient, upon initiating SFC services.

SFC is not available in all states. As of 2024, it is available in the following 8 states: Connecticut, Georgia, Indiana, Louisiana, Massachusetts, Missouri, North Carolina, and South Dakota. Nevada has initiated Structured Family Caregiving, but it has not yet been implemented. It is anticipated to be effective in January 2025.

SFC is a Medicaid long-term care benefit that is generally available through a Home and Community Based Services (HCBS) 1915(c) Medicaid Waiver. These programs limit the number of participant enrollment slots, and once all of the slots have been filled, a waiting list forms.

Benefits of Structured Family Caregiving

Structured Family Caregiving is a win-win for both caregivers and their care recipients. Since caregivers are paid to provide care, they can focus on being the primary caregiver without worrying about finances. They are also provided with the tools to provide the care their loved one requires. Care recipients can continue to live at home (or their loved one’s home), rather than require nursing home admission, and can continue to receive care from someone with whom they have an established relationship.

Care recipients receive 24-hour supervision and care in the shared home. This includes assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), such as bathing, personal hygiene, toileting, dressing, mobility, eating, medication management, light housecleaning, laundry, shopping for essentials, paying bills, and transportation to / from appointments. Caregivers may also help manage difficult behaviors, such as wandering, which is commonly seen in persons with dementia.

How Structured Family Caregiving Works & Payments to Caregivers

The caregiver, who lives with the care recipient, generally becomes a contractor or an employee of a home health agency or in-home provider agency. A care coordinator or social worker and a nurse oversee the caregiver, answer health-related questions, and provide emotional support. They ensure caregivers are trained and capable of providing the care their loved one requires and that they can continue to meet evolving needs. They are often required to write daily notes, which are reviewed by the agency in order to identify new needs. The agency also conducts home visits, generally about once a month.

Medicaid pays provider agencies a daily stipend, and a percentage of this sipend, generally 50% – 65%, is passed on to the caregiver as payment. The amount paid to the provider agency, and hence the caregiver, varies based on the state and may also vary based on the severity of the care recipient’s needs. For instance, in South Dakota, there are three levels of payment (eff. 7/1/24): base ($79.87 / day), tier 1 ($99.84 / day), and tier 2 ($111.82 / day). Of this, a minimum of 50% must be paid to the caregiver. Missouri, on the other hand, has only one rate of reimbursement, which is $92.09 / day (eff. 7/1/24). MO will not let their provider agencies keep more than 35% of this amount, or in other words, the caregivers receive a minimum of 65%.

Eligibility Criteria for Structured Family Caregiving

To be eligible for SFC, the caregiver and care recipient must live together in one of their homes. While the exact caregiver and care recipient requirements are based on the state and the Medicaid program through which Structured Family Caregiving is provided, generally speaking, the eligibility criteria is as follows.

Caregiver Eligibility

– Must be 18+ years old
– Must be committed to being the primary caregiver
– Must be able to provide the care required by the care recipient
– Must pass a background check

Note that some states will not allow a spouse to serve as the caregiver.

Care Recipient Eligibility

A care recipient must be eligible for the Medicaid program through which SFC is available. The following eligibility criteria is general and is not applicable to all states. Persons can find state-specific eligibility criteria in the chart at the bottom of this article by clicking on the name of the program that offers SFC in their state.

– Must have limited income. The income limit is generally $2,829 / month for the applicant. If there is a non-applicant spouse, their income is not counted towards the applicant’s income eligibility. Furthermore, the non-applicant spouse may be entitled to a Monthly Maintenance Needs Allowance from their applicant spouse.

– Must have limited assets. The limit is generally $2,000 for the applicant. If married, the assets of both the applicant and non-applicant spouse are considered jointly owned. The applicant spouse is generally allowed $2,000 in assets, while the non-applicant spouse is permitted a much larger allocation of assets as a Community Spouse Resource Allowance.

– Must have a functional need for care. This most commonly means one must require a Nursing Home Level of Care (NHLOC). Often this is exhibited by a need for assistance with Activities of Daily Living, such as bathing, dressing, mobility, toiletry, and eating.

State Specific Differences in Structured Family Caregiving

Not all states cover Structured Family Caregiving, and in those that do, it may go by a different name. For instance, the following states use the following names: Connecticut (Adult Family Living), Louisiana (Monitored In-Home Caregiving), Massachusetts (Adult Foster Care), and North Carolina (Coordinated Caregiving).

The rules surrounding this Medicaid benefit also tend to be state-specific. For instance, SFC is commonly available to care recipients who are aged and / or disabled, but Missouri requires that the care recipient have Alzheimer’s disease or a related dementia. Indiana, Louisiana, Missouri, North Carolina, and South Dakota allow a spouse to be hired as the caregiver, while other states, such as Connecticut, Georgia, and Massachusetts, prohibit a spouse from serving in this role. Furthermore, in Indiana, the caregiver is allowed to work outside of the home, but caring for their loved one must be their main priority. In contrast, in Georgia, it is required that a caregiver be unable to work outside the home due to the responsibility of caregiving.

Structured Family Caregiving Comparison Table / More Info by State

Not all states offer Structured Family Caregiving. The chart below includes the states that offer it or are in the process of implementing it. SFC will likely be made available in more states and this chart will be updated accordingly.