KFF surveyed Medicaid officials in all 50 states and D.C. between April-July 2025. Nearly all states (49 out of 50) allow Medicaid enrollees to self-direct their home care in some circumstances. Self-direction emerged from the "consumer-directed" movement, which began with demonstration programs in 19 states. All states with self-directed programs allow enrollees to select, train, and dismiss workers; 41 states allow enrollees to set worker pay; 39 allow them to allocate service budgets. All responding states pay family caregivers through one or more Medicaid home care programs. Self-direction is most common in waivers for people with intellectual/developmental disabilities (41 states) and older adults/physical disabilities (39 states).

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