Families have always played an essential role in caring for aging relatives and individuals with disabilities. However, providing ongoing care at home can be physically, emotionally, and financially demanding.
Structured Family Caregiving (SFC) is one approach that certain state Medicaid programs use to support individuals receiving care from someone who lives with them.
While the concept sounds straightforward, the regulatory requirements are not. Structured Family Caregiving is not a uniform national program, and it is not available in every state.
For home care agencies, prospective providers, and families, understanding how the model works—and how it differs from traditional home care—is an important first step.
What Is Structured Family Caregiving?
Structured Family Caregiving is a Medicaid-funded service model that allows an eligible individual to receive ongoing assistance from an approved live-in caregiver, often a family member, with training, support, and oversight provided through a participating agency.
The model is intended to support individuals who need assistance with daily activities and who can remain safely in a home environment with appropriate care and supervision.
Depending on the state and the participant's needs, covered assistance may include:
- Bathing, dressing, grooming, toileting, and mobility
- Meal preparation and household activities
- Assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
- Supervision and protective oversight
- Medication reminders or other permitted medication-related assistance
- Coordination with healthcare professionals and community resources
- Support for maintaining independence and participating in community life
Unlike a traditional home care arrangement, the primary caregiver generally resides with the person receiving care. The caregiver may be an adult child, another qualifying relative, or an approved unrelated person.
The caregiver's relationship to the participant, living arrangement, and qualifications must meet the rules of the particular state program.
How Does the Model Work?
Consider an older adult who requires assistance throughout the day because of physical limitations or cognitive impairment.
Rather than receiving all care from aides who arrive for scheduled shifts, the individual lives with a daughter who provides the daily assistance.
Under an approved Structured Family Caregiving arrangement:
- The individual qualifies for Medicaid and the applicable caregiving benefit. Eligibility and service needs are evaluated under state requirements.
- The live-in caregiver is reviewed and approved. The caregiver must meet applicable screening, training, competency, and other program requirements.
- An approved provider agency coordinates the service. The agency may conduct assessments, help develop the care plan, arrange caregiver training, and establish oversight.
- The caregiver provides the authorized daily support. The caregiver follows the individual's care plan and completes required documentation.
- The agency maintains ongoing monitoring and support. This may include home visits, professional oversight, caregiver coaching, health-status monitoring, and backup planning.
The agency generally receives Medicaid reimbursement and compensates the caregiver in accordance with the applicable program.
The arrangement supports the caregiver while establishing a formal system for monitoring the participant's health, safety, and service needs.
Is Structured Family Caregiving the Same as Traditional Home Care?
No. Although the services may overlap, the delivery models are different.
| Traditional Home Care | Structured Family Caregiving |
|---|---|
| Caregivers often travel to clients' homes for scheduled visits | The primary caregiver generally lives with the participant |
| Services are commonly scheduled and billed by the hour or visit | Reimbursement commonly uses a daily payment model |
| Agency personnel directly perform scheduled care | A live-in caregiver performs daily care with agency oversight |
| The agency manages visits, staffing, and supervision | The agency manages caregiver qualifications, coaching, monitoring, and program compliance |
| May serve private-pay or other authorized payer populations | Typically tied to a specific Medicaid benefit or approved managed care arrangement |
An important distinction is that a live-in caregiving arrangement does not mean Medicaid automatically reimburses 24 hours of hourly care every day. Payment is governed by the applicable service definition and authorization.
Can an Existing Non-Medical Home Care Agency Offer SFC?
Potentially, yes. However, an existing home care license does not automatically authorize the agency to provide or bill Structured Family Caregiving.
The agency must qualify under the state's specific service-provider requirements.
These may involve separate Medicaid enrollment, waiver-provider certification, additional accreditation, managed care contracting, service-specific staffing, caregiver training, and operational policies.
In Ohio, for example, the requirements for agencies participating in PASSPORT differ from those applicable under the Ohio Home Care waiver.
A licensed agency considering SFC should first determine whether its existing license satisfies any applicable prerequisite and what additional approvals are required.
Simply adding SFC to an agency's list of services is not sufficient.
Can Someone Establish a Standalone Structured Family Caregiving Agency?
A business focused on SFC may be possible where the provider framework permits it.
A company may be established primarily or exclusively to operate as an approved SFC provider, without necessarily offering traditional hourly home care services.
However, a standalone business model does not mean the organization is exempt from licensing, certification, Medicaid enrollment, or provider qualification requirements.
Provider classifications differ. Participating organizations may need to qualify under an existing home care, personal care, or HCBS provider framework; a business name or service focus does not establish a separate licensing category.
Some programs also establish experience requirements that may limit entry by new organizations.
An individual family caregiver generally cannot simply establish an LLC and begin billing Medicaid independently for agency-directed SFC services.
Before investing in a new SFC business, prospective providers should confirm the state's current provider classification, entry qualifications, application status, required licenses or certifications, and enrollment process.
Is Structured Family Caregiving Available in Every State?
No. Structured Family Caregiving is a state-specific Medicaid service, and not all states participate.
Federal Medicaid law gives states considerable flexibility in designing Home and Community-Based Services (HCBS) programs. States may establish services for certain populations, specify provider qualifications, and determine how services will be authorized and reimbursed.
These programs frequently operate through Medicaid HCBS waivers under Section 1915(c) of the Social Security Act. Other states use different Medicaid authorities or managed care arrangements.
KFF’s January 2026 analysis of its 2025 Medicaid survey reported Structured Family Caregiving in the following 11 states within the waiver categories examined:
Connecticut, Georgia, Indiana, Louisiana, Missouri, New Hampshire, North Carolina, North Dakota, Ohio, Rhode Island, and South Dakota.
Additional states have comparable or differently authorized models. For example, Massachusetts operates an Adult Foster Care program, Nevada has a separate Structured Family Caregiving waiver, and Florida permits an SFC in-lieu-of-service option under certain Medicaid managed care plans.
The survey is a historical snapshot of the categories examined, rather than a complete October 2026 enrollment directory. Florida did not respond to the survey.
A state may also permit family members to receive payment through consumer-directed personal care without operating a formal SFC program.
The fact that a state pays family caregivers does not, by itself, establish that the state offers Structured Family Caregiving.
Examples of How State Programs Differ
The following examples show why a provider must identify the particular benefit and its entry requirements before developing an agency model.
| State | Program distinctions |
|---|---|
| Indiana | Recognizes SFC through Medicaid HCBS programs, including PathWays for Aging. Service-specific provider standards apply. See the dated enrollment note below. |
| Georgia | DCH recognizes SFC and announced proposed additional program-integrity requirements and an enrollment timetable in April 2026. See the dated note below. |
| Ohio | Rule 5160-44-33 addresses SFC under MyCare, Ohio Home Care, and PASSPORT waivers. Ohio Home Care uses specified agency accreditation or Medicare certification requirements; PASSPORT requires Ohio Department of Aging certification. |
| North Carolina | Calls the service Coordinated Caregiving under CAP/DA and CAP/C. Both programs publish service-specific provider application materials. |
| Missouri | Has an approved SFC waiver renewed effective July 1, 2026. CMS describes eligibility for adults aged 65 or older and adults aged 21–64 with other disabilities who meet a nursing facility level of care. Applicants must confirm the detailed eligibility criteria in the current waiver. |
| Nevada | Has an approved SFC waiver effective January 1, 2025. State law addresses a dementia-focused live-in caregiving arrangement and specifies agency/intermediary participation, caregiver employment, and compensation requirements. |
| Massachusetts | Offers a comparable Adult Foster Care benefit through MassHealth, with a qualified live-in caregiver, nursing oversight, and care management. |
| Florida | AHCA lists SFC as an optional in lieu of service alternative to nursing facility services. Availability depends on agency approval and the participating health plan's contract and benefit offering. |
Sources: Indiana provider manual, Ohio rule, NC CAP/DA, NC CAP/C, Missouri CMS factsheet, Nevada waiver, Nevada statute, NRS 422.3965, MassHealth factsheet, and Florida AHCA overview.
Provider Enrollment Notices — October 8, 2026
An established Medicaid benefit may still be closed to new provider applications.
Indiana: IHCP Bulletin BT2026124, issued July 23, 2026, established an HCBS provider certification and enrollment moratorium effective August 1, 2026, for an initial six months. SFC is among the affected services. The bulletin also addresses ownership changes, added counties, and added services, with limited access-related exceptions. Application treatment depends on the waiver and application status.
Georgia: DCH's April 28, 2026 announcement proposed additional SFC requirements and announced an October 2026 timetable for ownership changes and expansion requests and a March 2027 timetable for new providers. The announcement said final decisions would be communicated through provider banner messages. These are the announcement's stated dates; applicants should confirm subsequent final policy and enrollment instructions directly with DCH before relying on them.
Who Qualifies to Receive Structured Family Caregiving?
Eligibility is determined by the state program and may involve several considerations.
Common requirements include Medicaid eligibility, participation in a qualifying waiver or managed care plan, assessed needs for daily assistance or supervision, an approved living arrangement, and an eligible live-in caregiver.
Some programs serve older adults and people with physical disabilities. Others focus on intellectual or developmental disabilities, medically complex children, or individuals with dementia.
Certain waivers require participants to meet a nursing facility level of care. Others have different functional or clinical eligibility criteria.
Receiving Medicaid alone does not automatically qualify someone for SFC. The person must also qualify for the particular service, and that service must be authorized.
Waiver enrollment capacity, provider availability, and managed care plan participation can also affect access.
Can a Spouse, Adult Child, or Other Family Member Be Paid?
Potentially, but this is another area where state-specific rules are critical.
States differ in whether spouses, parents of minor children, legal guardians, adult children, and other relatives can serve as paid caregivers.
For example, Nevada law, NRS 422.3965, expressly includes spouses and legally responsible caregivers in its waiver framework. MassHealth’s Adult Foster Care factsheet, by contrast, excludes spouses and legal guardians as caregivers. These examples do not establish eligibility under another state's program.
Caregiver screening, training, employment or contractor status, compensation requirements, and restrictions on other employment may also differ.
Families should not assume that qualifying for one Medicaid family caregiver program automatically establishes eligibility for another.
How Are SFC Agencies and Caregivers Paid?
Many SFC programs use a per diem, or daily reimbursement arrangement, rather than the hourly billing commonly associated with traditional home care.
The approved agency receives payment for authorized services and compensates the caregiver according to the state's applicable requirements.
The agency's reimbursement also supports its administrative and program responsibilities, including caregiver training, professional monitoring, documentation, compliance, and service coordination.
Some states specify how much of the daily reimbursement must be paid to the caregiver. Others establish different compensation arrangements.
There is no single national SFC payment rate or uniform caregiver compensation formula.
For prospective agency owners, financial planning must consider not only the Medicaid reimbursement rate but also the cost of required professional personnel, caregiver compensation, home visits, administrative operations, technology, and compliance oversight.
The availability of a daily Medicaid rate should not be interpreted as guaranteed agency revenue or profit.
What Responsibilities Does the SFC Provider Agency Have?
Although a family member or other live-in caregiver provides the daily assistance, the approved provider agency remains accountable for the responsibilities assigned to it under the Medicaid program.
Depending on the state, these may include:
- Evaluating and approving caregivers and residential settings
- Verifying background checks, qualifications, and training
- Developing and maintaining individualized service plans
- Coordinating nursing, social work, or other required professional oversight
- Conducting scheduled home visits and caregiver coaching
- Monitoring participant condition, safety, and satisfaction
- Arranging substitute caregivers or backup care
- Maintaining daily service records and supervisory documentation
- Reporting incidents, suspected abuse, and changes in condition
- Ensuring accurate Medicaid claims and compliance with billing limitations
- Protecting participant rights and maintaining quality oversight
The details matter. Requirements for nursing involvement, caregiver training hours, home visits, documentation, and Electronic Visit Verification (EVV) are not identical across programs.
In addition, providing SFC does not automatically authorize a caregiver or agency to perform skilled nursing activities. Clinical services and delegated tasks remain subject to applicable professional practice laws, service definitions, and program requirements.
Are Specialized Policies and Procedures Required?
Structured Family Caregiving involves regulatory responsibilities that may not be fully addressed in a conventional non-medical home care policy manual.
An organization may need written policies and supporting documentation addressing:
Organizational requirements: Medicaid program participation, provider qualifications, responsible personnel, participant admission, rights, and service authorization.
Caregiver requirements: Screening, qualifications, training, competency, agreements, compensation, supervision, and substitute caregiver arrangements.
Participant care: Individualized service planning, daily supervision, condition monitoring, emergency procedures, and transitions of care.
Compliance and quality: Documentation standards, professional oversight, incident reporting, complaints, quality improvement, record retention, and billing integrity.
Some agencies may be able to incorporate these requirements through a service-specific addendum to an existing manual. Others may need a complete SFC operational manual.
The appropriate approach depends on the state's provider classification, applicable regulations, and the agency's existing services.
Is Structured Family Caregiving the Same as Consumer-Directed Care?
Not necessarily.
Consumer-directed care generally allows an eligible Medicaid participant or authorized representative to exercise control over selecting, directing, and sometimes employing their caregiver. A financial management service may handle payroll and related administrative functions.
Structured Family Caregiving generally uses a provider-agency model in which the agency assumes specified responsibilities for caregiver support, oversight, and program compliance.
Both approaches may allow family members to provide paid care, but the regulatory and operational responsibilities can be substantially different.
What Should an Agency Verify Before Pursuing SFC?
Before applying to establish an SFC provider or add the service to an existing business, the following questions should be answered:
- Does the state offer SFC or a comparable live-in caregiving benefit?
- Under which Medicaid waiver, state-plan authority, or managed care arrangement is it available?
- Is the service currently open to new providers?
- Is a traditional home care license required, or is another provider certification available?
- Can a new standalone company qualify, or is previous HCBS experience required?
- Are accreditation, professional staffing, or managed care contracts necessary?
- What participant populations and caregiver relationships are eligible?
- What policies, procedures, operational records, and oversight systems are required?
- What reimbursement and caregiver compensation rules apply?
- Are there restrictions on service availability, participant enrollment, or simultaneous use of other services?
Answering these questions before submitting applications or developing operational documents can help prevent costly misunderstandings.
Preparing to Offer Structured Family Caregiving
SFC combines daily assistance from a live-in caregiver with formal agency support, training, monitoring, and program accountability. It can offer a path for existing agencies to expand or for businesses to specialize, where the provider requirements and enrollment process allow it.
Before committing to the model, confirm the benefit, provider classification, required approvals, staffing, caregiver rules, and reimbursement structure. Then select policies and operational tools that reflect those requirements.
Considering this model? Start by confirming the provider requirements in your state before selecting policies or application support.
Sources and Further Reading
- CMS — Home and Community-Based Services, Section 1915(c)
- KFF — Medicaid's Home Care Support for Family Caregivers in 2025
- Indiana Medicaid — PathWays for Aging HCBS Provider Manual
- Indiana Medicaid — Provider Moratorium Bulletin BT2026124
- Ohio Administrative Code — Rule 5160-44-33
- North Carolina Medicaid — CAP/DA Coordinated Caregiving
- CMS — Missouri Structured Family Caregiving Waiver
- CMS — Nevada Structured Family Caregiving Waiver
- MassHealth — Adult Foster Care Program
- Georgia DCH — 2026 Medicaid Program Integrity Announcement
- Florida AHCA — Medicaid In-Lieu-of-Services Overview
Regulatory information is provided for general educational purposes. Medicaid programs and provider participation requirements are subject to change. Organizations should verify current requirements with the applicable state Medicaid and licensing authorities before making operational or enrollment decisions.