How Medicaid Pays for Home Care in Maryland

Community First Choice: the Maryland benefit that cannot be capped

Maryland Community First Choice is the state's attendant-care benefit, and it is built under Section 1915(k) of the Social Security Act rather than under a waiver. That choice carries consequences. A 1915(k) program covers help with daily activities, household tasks, and health-related tasks as a state plan benefit; it must serve people who meet an institutional level of care; and, the part that matters most here, the state cannot cap enrollment 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).That Section 1915(k) Community First Choice provides home- and community-based attendant services as a state plan benefit, that participating states receive a 6-percentage-point FMAP increase, that it must serve people meeting an institutional level of care, and that states cannot cap its enrollment — the structure behind Maryland Community First Choice having no waiting list..

Community First Choice is an entitlement in Maryland. Qualifying is the gate. There is no slot to wait for, because federal law does not permit one.

That is the reverse of how most states pay for attendant care, and it is the first thing worth establishing about any particular Maryland situation.

The benefit covers personal assistance with bathing, dressing, transferring, toileting, and eating, along with the household work attached to them, plus supports planning, a personal emergency response system, and items that substitute for human help.

States adopting Community First Choice receive a 6-percentage-point increase in their federal Medicaid match for those services 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).That Section 1915(k) Community First Choice provides home- and community-based attendant services as a state plan benefit, that participating states receive a 6-percentage-point FMAP increase, that it must serve people meeting an institutional level of care, and that states cannot cap its enrollment — the structure behind Maryland Community First Choice having no waiting list..

Maryland took that deal. The money is why the option exists and why Maryland's structure looks the way it does.

Community Personal Assistance Services, and the level-of-care line

Community Personal Assistance Services is Maryland's route for people who need hands-on help but do not meet a nursing facility level of care. That line matters because Community First Choice, by federal design, must serve people who meet an institutional level of care 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).That Section 1915(k) Community First Choice provides home- and community-based attendant services as a state plan benefit, that participating states receive a 6-percentage-point FMAP increase, that it must serve people meeting an institutional level of care, and that states cannot cap its enrollment — the structure behind Maryland Community First Choice having no waiting list.. Someone who genuinely struggles to bathe and dress, but who would not be admitted to a nursing home tomorrow, sits below that bar. Community Personal Assistance Services is what catches them.

It is also a state plan benefit rather than a waiver, so the same logic holds: qualifying is the gate, not a slot.

The level-of-care finding is the hinge of the entire Maryland system. It decides which program applies, which application gets filed, and which assessment runs.

This is not an academic distinction, and it is the one Maryland families most often get wrong on the first phone call. Asking directly whether an assessment is being run against the nursing facility level of care, and what the finding was, is a reasonable and specific question to put to the state. The Maryland Department of Health publishes criteria for both programs, and a finding can be appealed.

The Community Options Waiver, and where Maryland's wait actually sits

The Community Options Waiver is Maryland's 1915(c) program, and it is where the waiting lives. A 1915(c) waiver covers home and community services as an alternative to institutional care on a condition of cost neutrality: it cannot cost Medicaid more than the facility it replaces 2Ref 2Centers for Medicare & Medicaid Services (2025).Home & Community-Based Services 1915(c).That a 1915(c) waiver covers services at home as an alternative to institutional care, that it must be cost-neutral against institutional care, and that states may cap enrollment and target specific populations — the structure behind the Community Options Waiver's registry.. To hold that promise, states are permitted to cap enrollment and to aim the waiver at a particular population 2Ref 2Centers for Medicare & Medicaid Services (2025).Home & Community-Based Services 1915(c).That a 1915(c) waiver covers services at home as an alternative to institutional care, that it must be cost-neutral against institutional care, and that states may cap enrollment and target specific populations — the structure behind the Community Options Waiver's registry.. Maryland does both.

A registry is a date-stamped queue for a capped waiver. It is not an application, and a place on it is not coverage.

What the waiver adds is what the state plan benefits do not reach, including assisted living as a setting and certain services that arrive bundled with waiver enrollment.

Waiver queues are the national norm rather than a Maryland quirk: 41 states kept a waiting or interest list in 2025, and the average wait for waiver services stretched to about 32 months 3Ref 3KFF (Kaiser Family Foundation) (2025).A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2025.That 41 states kept an HCBS waiting or interest list in 2025, that roughly 0.7 million people were on such a list, and that the average wait for waiver services was about 32 months..

Here is the Maryland-specific point, stated plainly: a person waiting on the Community Options Waiver registry may already qualify for Community First Choice attendant care today. The wait is for the waiver's additions, not for the hands-on help. Families who never learn this spend years waiting for something they could have had throughout.

Maryland Access Point, supports planning, and how an application moves

Maryland routes long-term services through Maryland Access Point, the state's information and assistance network, and it tracks applications and plans of service in LTSSMaryland, the state's online long-term services system. Once someone is enrolled, a supports planner — Maryland's term for the person who builds and monitors the plan of service — becomes the human being who makes the system move. Knowing those three names shortens most phone calls.

The money screen runs separately from the functional one. They are two independent determinations, and clearing one does not clear the other. Maryland resets its income and asset standards every year, which is why no dollar figure belongs in a health article, this one included. The Maryland Department of Health posts the current standards, and those are the numbers that decide.

There is a sequencing point that almost nobody is told. The financial application and the functional assessment can be started in parallel rather than one after the other. Many households run them in sequence simply because nothing in the process suggests otherwise, and the sequence costs time the parallel path does not.

Hiring your own attendant, and paying a relative, in Maryland

Maryland's Community First Choice runs in both an agency model and a self-directed model, and the self-directed model is where the family-caregiver question gets its answer. Self-direction in Medicaid hands the participant both the budget and the hiring: they choose, train, and supervise the worker themselves, and some states allow that worker to be a relative 4Ref 4Centers for Medicare & Medicaid Services (2025).Self-Directed Services.That Medicaid self-direction lets a participant manage a budget and select, hire, train, and manage their own caregivers, and that some states permit a family member to be the paid worker.. Maryland offers self-direction inside Community First Choice.

Legal responsibility, not affection or effort, is what usually decides whether a relative can be paid.

Spouses and parents of minor children are the relationships most often excluded, since the state already counts that care as an existing obligation. Adult children, siblings, and grandchildren are the ones most often permitted. Maryland publishes its own version of that line and has moved it before, so the state's current rule beats any summary.

Self-direction also hands the household the employer's job: recruiting, scheduling, covering the shift when a worker's car will not start, and having a hard conversation with the person who bathes their mother. A financial management service handles payroll and the employment taxes. The rest is real work that no one warns about in advance.

Money Follows the Person: leaving a Maryland nursing facility

Money Follows the Person is the federal demonstration that funds states to transition Medicaid beneficiaries out of institutions and back into homes and community settings 5Ref 5Centers for Medicare & Medicaid Services (2025).Money Follows the Person.That the Money Follows the Person demonstration funds states to transition Medicaid beneficiaries out of institutions such as nursing facilities into community and home settings.. Maryland has used it. For a family whose relative is already in a nursing facility, it is the most underused door in the system, because it reverses the usual order: the person is moved toward home services on the way out rather than having to assemble everything first.

A nursing home admission is not automatically permanent, and asking about transition programs is a normal request rather than an imposition on the staff.

The work is genuinely hard. Somewhere to live has to exist, the home has to be physically workable, and services have to start the week the person arrives, not a month later. But the funding is built for that exact sequence, and Maryland's attendant benefit being uncapped means the help waiting on the other side is not itself a queue.

A person in a facility, or their family, can ask the social worker about transition programs by name. Asking is frequently what starts the process.

What Maryland Medicaid will not pay for at home

The gaps are predictable, and they are worth knowing before a plan is built around a wrong assumption. Maryland Medicaid does not pay a family to be present around the clock. It does not fund room and board in a person's own home. And Medicare, which most older Marylanders assume covers this, does not fill the gap: its home health benefit is skilled, intermittent, and hung on an episode of illness, and custodial care falls outside it 6Ref 6Administration for Community Living (2025).Costs of Care.That Medicare does not pay for ongoing custodial or personal care, and that home care is generally paid out of pocket, by Medicaid for those who qualify, or by long-term care insurance..

That narrows the payers for home care to three: private savings, Medicaid for those who qualify, and long-term care insurance 6Ref 6Administration for Community Living (2025).Costs of Care.That Medicare does not pay for ongoing custodial or personal care, and that home care is generally paid out of pocket, by Medicaid for those who qualify, or by long-term care insurance.. For most households the middle one is the only realistic door, which is why the level-of-care finding carries so much weight.

The national account of medicaid home care explains how the federal authorities behind all of this fit together, and it is the right page for that question. What belongs to Maryland alone is the shape: an uncapped attendant benefit, a state plan option for people below institutional level of care, and a waiver holding the extras. A reader asking does medicaid pay for home care will find that medicaid home care in louisiana is built on entirely different bones.