Consumer Directed Services in Missouri: how a relative becomes a paid caregiver

What the Missouri CDS program is

CDS is one of the Home and Community-Based Services (HCBS) offered by DSDS, part of the Missouri Department of Health and Senior Services. The state's HCBS manual (section 3.25, revised January 2026) describes it as hands-on help with activities of daily living, offered to people with a physical disability as an alternative to moving into a nursing facility.

"Consumer directed" means the participant hires, trains, supervises and directs the attendant, and the manual names the participant as employer of record. Under Missouri's agency model, by contrast, the DHSS questions page says the caregiver cannot be an immediate family member, so ask for CDS if you want a relative paid.

Covered tasks include bathing, dressing, toileting, transfers, meals and feeding, help with medications, laundry and essential transportation for errands, school or work.

Who qualifies for consumer directed services in Missouri

The manual lists the eligibility tests for the person receiving care:

• At least 18 years old.
• Physically disabled under 19 CSR 15-8.100: a loss, or loss of use, of neurological, muscular or skeletal function serious enough that another person must help with routine tasks.
• Active Medicaid (MO HealthNet) status with an appropriate eligibility code. People on a spenddown can be authorized for the months they meet it.
• A nursing facility level of care, set through an in-home assessment.
• Able to self-direct: supervise the attendant, verify wages, monitor Electronic Visit Verification (EVV) use, and report changes and problems.
• No previous involvement in Medicaid fraud.

Someone who lives in a nursing facility, residential care facility or assisted living facility is not eligible. A person with a physical disability who needs a designated person to help run the program because of a cognitive impairment can be served only through the Independent Living Waiver, described below.

How to apply: MO HealthNet first, then an HCBS referral

1. Medicaid. Apply for MO HealthNet through the myDSS online portal or by phone at 855-373-9994. Anyone 65 or older, blind or disabled, on Social Security or with Medicare also files the Supplemental Form. If you hear nothing from the Family Support Division within 45 days, contact it.
2. HCBS referral. Submit the online HCBS referral form or call HCBS Intake at 1-866-835-3505. Anyone can make the referral, including a relative, friend or doctor.
3. Assessment. If the minimum requirements are met, an assessment team schedules a face-to-face visit to measure level of care and unmet needs.
4. Care plan. DSDS and the participant build a person-centered care plan (PCCP) that sets the authorized tasks and minutes. Say at this stage that you want CDS and which relative will be the attendant.
5. Annual review. Needs and eligibility are reassessed every year.

Family members who can be the paid attendant, and the two who cannot

The CDS manual states it plainly: the attendant may be a family member, but cannot be the participant's spouse or legal guardian. The DHSS questions page puts it the same way, saying a participant can hire anyone except a legal spouse or guardian. Adult children, grandchildren, siblings, nieces and nephews, in-laws and friends are therefore all possible attendants.

• The attendant cannot be a CDS participant or have past Medicaid fraud.
• Every caregiver must pass a background check, according to the HCBS questions page. State law also makes personal care workers register with the Family Care Safety Registry, whose registration fee rose to $16.00 on October 1, 2026.

CDS serves adults only, so the manual has no parent-of-a-minor rule.

Who runs payroll, hours and what CDS will not pay for

The participant picks an HCBS provider that is enrolled as a CDS provider with Missouri Medicaid Audit and Compliance (MMAC). Medicaid pays that provider, and the provider processes payroll to the attendant on the participant's behalf. Under the CDS tax appendix (revised April 2026) the provider files and pays payroll and employment taxes using the participant's tax ID, has the participant sign IRS Form 2678 to appoint it as agent, and is answerable for garnishments caused by its own late filings.

Time is authorized in 15-minute units. CDS on its own, or combined with agency personal care, may not exceed 60% of the participant's HCBS cost maximum, a monthly ceiling guided by the cost of nursing facility care. The manual rules out payment for:

• stand-by help, prompting or cueing;
• respite, or time spent waiting at appointments;
• chores whose main benefit goes to the whole household, or tasks household members would normally share, unless the need goes beyond what a household member without a disability would require;
• anything that must be done or trained by a licensed professional, such as skilled nursing.

Two related Missouri waivers: ILW and Structured Family Caregiving

Independent Living Waiver (ILW)

ILW adds self-directed personal care hours once State Plan CDS limits are reached, plus case management, financial management services, home adaptations and specialized medical supplies. Applicants must be 18 to 64 when they first enroll and may stay past 65 if they can still self-direct. ILW personal care is capped at 868 units a month. The waiver has a fixed number of slots per waiver year (July 1 to June 30); when they fill, eligible people go on a waitlist ranked by level-of-care scores.

Structured Family Caregiving Waiver (SFCW)

SFCW is for people 21 and older whom a Missouri-licensed physician has diagnosed with Alzheimer's or a related dementia disorder and who live full time with their primary caregiver. That caregiver must already be the live-in caregiver before the waiver starts, and the manual says the primary and substitute caregivers may be a family member, a non-family member or a legal guardian. Payment is a daily unit based on 60% of the nursing facility daily rate; the enrolled provider may keep no more than 35% and must pay the caregivers. SFCW cannot be combined with any other HCBS, and slots are limited each waiver year. The manual does not address spouses as SFCW caregivers, so ask DSDS directly.

How much a paid family caregiver earns in Missouri

Missouri does not publish a single statewide hourly wage for CDS attendants; the wage is confirmed between the participant and the CDS provider that runs payroll. Two official figures give a frame of reference. They are not program rates.

Monthly pay follows the minutes in the care plan, not every hour you spend with your relative.

Other routes: VA programs and how the IRS treats the pay

• VA caregiver stipend (PCAFC). Missouri families caring for a veteran can ask the VA about PCAFC (Program of Comprehensive Assistance for Family Caregivers). It adds a monthly payment for the designated Primary Family Caregiver. On the veteran's side, VA lists a combined or single disability rating no lower than 70%, a military discharge (or a set medical discharge date), at least half a year of expected hands-on care needs, and VA health care enrollment. The caregiver has to be an adult relative, spouse included, or someone living with the veteran full time.
• Veteran Directed Care. Here the VA gives the veteran a budget, and a counselor helps with a spending plan and with recruiting helpers, a relative or neighbor among them. It is not available at every VA location.
• Taxes. Under IRS Notice 2014-7, pay from a Medicaid 1915(c) waiver can be left out of income when the care happens in the home the caregiver lives in. State Plan CDS is not a waiver, and for non-waiver programs the IRS Q&A says its treatment turns on program design; your CDS provider can tell you how it reports attendant wages. For private hires, IRS Topic 756 puts the 2026 household-employee threshold for withholding FICA at $3,000 in cash wages.

Area Agencies on Aging and adult abuse reporting in Missouri

Ten Area Agencies on Aging cover every Missouri county. The Missouri Senior Resource Line, 1-800-235-5503, asks for your ZIP code and transfers you to the local agency, which can explain caregiver support and in-home services in your area. In the Kansas City area, see our Kansas City and Platte City pages for local contacts.

If you suspect an older or disabled Missourian is being harmed through abuse, neglect or exploitation, phone the Adult Abuse and Neglect Hotline at 1-800-392-0210, open 7 a.m. to 8 p.m. every day, or report online through DHSS. Relay Missouri is 1-800-735-2966.

Where CaregiverConnect fits

To be clear about our role: CaregiverConnect does not hold a MO HealthNet contract, act as a CDS provider or payroll agent, or sign anyone up for CDS, ILW or SFCW. It is a place where Missouri families who pay out of pocket, or who want help beyond the authorized minutes, post a care job at no cost, talk to applicants and hire one themselves. The family that hires is the household employer. DHSS notes that private-pay single-service home care has no state license or oversight, so check references. On the other side, Missouri caregivers list their experience in a no-cost profile and answer the posts that suit them. Read how it works, see pricing for optional plans, and try the guides on hiring privately and Medicaid options for relatives who give care. For other states, compare consumer directed care in Virginia or STAR+PLUS CDS in Texas.

Frequently asked questions

Sources

1. Missouri DHSS, HCBS Manual 3.25 Personal Care Assistance, State Plan (Consumer-Directed Service Model), revised January 2026
2. Missouri DHSS, HCBS Manual 3.25 Appendix 1, Consumer Directed Services Tax Information, revised April 2026
3. Missouri DHSS, HCBS Manual 3.55 Independent Living Waiver, revised July 2026
4. Missouri DHSS, HCBS Manual 3.60 Structured Family Caregiving Waiver, revised March 2025
5. Missouri DHSS, Apply for Home and Community-Based Services
6. Missouri DHSS, HCBS Eligibility, Process and Program Limits
7. Missouri DHSS, Frequently Asked Questions About HCBS
8. Missouri DSS, Apply for MO HealthNet
9. Missouri DHSS, The 3 Types of Care in the Home (PDF)
10. Missouri DHSS, Family Care Safety Registry
11. Missouri DHSS, Area Agencies on Aging
12. Missouri DHSS, Stop Adult Abuse (Adult Abuse and Neglect Hotline)
13. Missouri Department of Labor, Minimum Wage
14. BLS OEWS May 2025, home health and personal care aides (31-1120), Missouri (OEWS data query)
15. IRS, Certain Medicaid waiver payments may be excludable from income (Notice 2014-7 Q&A)
16. IRS, Topic no. 756, Employment taxes for household employees
17. VA, Program of Comprehensive Assistance for Family Caregivers
18. VA, Veteran Directed Care