What is Cardinal Care consumer-directed care?
Cardinal Care is the name for Virginia Medicaid, and its home-based long-term care benefit is delivered through the CCC Plus Waiver (the Commonwealth Coordinated Care Plus 1915(c) waiver). This waiver provides personal care, respite, and related services in a person's own home or community instead of a nursing facility. Within the waiver, Virginia offers a "consumer-directed" (CD) model of service delivery that lets the member employ their own attendant, including many family members.
Under the consumer-directed model, the member receiving services (or a designated representative acting as the Employer of Record) performs all of the employer responsibilities: hiring, training, scheduling, supervising, and if necessary terminating the attendant. This is the opposite of the traditional "agency-directed" model, where a home care agency assigns and supervises an aide. Consumer direction is built on the idea that the person who needs care, or a family member close to them, is best positioned to choose and manage who provides it.
Because the member is the employer, no formal certification is required of the attendant. An adult daughter who has quietly cared for her father for years can be hired and paid, as long as her father is enrolled in Virginia Medicaid and meets the nursing-facility level-of-care requirement. The services that can be consumer-directed are personal care (also called personal assistance), respite care, and companion services.
Two support entities make the program work. A Services Facilitator provides information and helps the member and family learn the responsibilities of being an employer of record. A Fiscal/Employer Agent (F/EA) handles the financial side of employment: withholding taxes, running payroll, and issuing the attendant's paychecks. In Virginia, the F/EA is Public Partnerships LLC (PPL) or Consumer Direct Care Network Virginia (CDCN), depending on the member's managed care plan.
Cardinal Care CCC Plus Waiver eligibility
To use consumer-directed care, the person receiving services must qualify for the Virginia Medicaid CCC Plus Waiver. This means meeting both a functional (medical) test and a financial test. The attendant does not have to meet income or asset limits; only the member does.
Who can - and cannot - be paid through Cardinal Care CD
Virginia's consumer-directed model lets the member hire most family members and even friends. Spouses and parents of minor children were historically excluded, but Virginia now allows them to be paid under a separate set of rules for Legally Responsible Individuals (LRIs).
- Adult children (18 or older) of the member
- Siblings, grandchildren, nieces, nephews, aunts, uncles, and in-laws
- Adult friends, neighbors, or members of the member's faith community
- A spouse - but only as a Legally Responsible Individual (see below), limited to 40 hours per week for extraordinary care
- A parent of a minor child receiving care - also only under the LRI rules, capped at 40 hours per week
- An Employer of Record can hire almost anyone the member trusts who meets basic worker requirements
- A spouse or parent of a minor who is NOT approved under the Legally Responsible Individual (LRI) process
- The same person acting as both the Employer of Record and the paid attendant (roles must be separate)
- An attendant paid for more than 40 hours per week when they are a spouse or parent serving as an LRI
- Anyone providing only instrumental ADLs (housekeeping, errands) or general supervision as an LRI - that care does not count as payable extraordinary care
Cardinal Care CD pay, hours, and overtime
Virginia sets consumer-directed personal care rates by region and updates them roughly every year through the state budget. The number of hours a member receives is based on the UAI assessment of their needs. The rate the state pays covers both the attendant's wage and the employer taxes the Fiscal/Employer Agent must withhold, so the attendant's take-home wage is somewhat lower than the posted reimbursement rate.
Hourly pay
Effective July 1, 2025, the Virginia Medicaid consumer-directed personal care reimbursement rate (procedure code S5126) is about $17.97 per hour in Northern Virginia (NOVA) and about $13.88 per hour in the rest of the state (ROS). That figure is the total rate paid to the Fiscal/Employer Agent; after employer payroll taxes and administrative costs are taken out, a typical attendant take-home wage lands roughly in the $13-$16 per hour range in Northern Virginia and around $11-$13 per hour elsewhere. Attendants are W-2 employees, so federal and state income tax, Social Security, and Medicare are withheld. Ask your Fiscal/Employer Agent (PPL or Consumer Direct) for the exact current attendant wage.
Hours and scheduling
Authorized hours come from the UAI assessment and the member's plan of care. Many members receive somewhere between 15 and 40 hours per week of personal care, though higher-need members may be approved for more. The member can split their approved hours across more than one attendant. Important: when a spouse or the parent of a minor is the paid attendant under the Legally Responsible Individual rules, reimbursement is capped at 40 hours per week, and respite care cannot be paid at the same time an LRI is providing personal care.
Overtime rules
Federal Fair Labor Standards Act overtime rules apply to home care workers in Virginia. An attendant who works more than 40 hours in a single workweek for one member is generally owed overtime at 1.5x their regular rate. Because Medicaid authorizes a fixed number of hours, many families schedule two or more attendants to cover the week and avoid triggering overtime. The Fiscal/Employer Agent tracks hours and handles any overtime calculation.
How to apply for Cardinal Care consumer-directed care in Virginia
- Confirm the person receiving care has Virginia Medicaid, or apply for it. You can apply online at commonhelp.virginia.gov, by calling the Cover Virginia Call Center at 1-833-522-5582, or through your local Department of Social Services (DSS).
- Request a screening for the CCC Plus Waiver. The screening determines whether the person meets the nursing-facility level of care using the Uniform Assessment Instrument (UAI).
- Contact your local Department of Social Services or health department to request the community-based screening
- A nurse and a social worker (the screening team) evaluate ADL needs in person
- Be ready to describe help needed with bathing, dressing, transferring, toileting, and eating
- Enroll in the CCC Plus Waiver and a Cardinal Care Managed Care (CCMC) health plan. As of July 1, 2025 the CCMC plans are Aetna, Anthem HealthKeepers Plus, Humana Healthy Horizons, Sentara Health Plans, and UnitedHealthcare. Your care coordinator authorizes the waiver services.
- Choose consumer direction and get set up with a Services Facilitator and a Fiscal/Employer Agent.
- Tell your care coordinator you want the consumer-directed (CD) model, not agency-directed
- The Services Facilitator helps you learn the Employer of Record responsibilities
- Your health plan assigns the Fiscal/Employer Agent (Public Partnerships/PPL or Consumer Direct Care Network Virginia/CDCN)
- Hire your attendant and complete their enrollment paperwork through the Fiscal/Employer Agent.
- Federal I-9 employment eligibility verification and W-4 tax forms
- Criminal background check and any required registry checks
- If the attendant is a spouse or parent of a minor, request review under the Legally Responsible Individual (LRI) rules and document the extraordinary care needed
- Submit timesheets each pay period. The member or Employer of Record approves the hours worked, and the Fiscal/Employer Agent processes payroll and issues the paycheck, usually every two weeks. The plan of care is reassessed at least once a year.
Cardinal Care Virginia frequently asked questions
Can my spouse be paid to care for me in Virginia?
Sometimes, yes. This is a recent change. For years, Virginia Medicaid did not allow a spouse (or the parent of a minor child) to be a paid attendant. Virginia now permits it through the Legally Responsible Individual (LRI) rules, which took effect in late 2023 and were updated effective July 1, 2025. To be paid, a spouse must provide personal care that is "extraordinary in nature," meaning above and beyond the ordinary care spouses normally provide each other. Reimbursement for an LRI is capped at 40 hours per week, and respite care cannot be paid at the same time. Instrumental tasks like housekeeping and general supervision do not count as payable extraordinary care. If you want a spouse paid, ask your Services Facilitator or care coordinator to review your case specifically under the current LRI rules, since some older summaries still say spouses can never be paid.
How much does Cardinal Care consumer-directed care pay in 2026?
Virginia sets consumer-directed personal care rates by region. Effective July 1, 2025, the state reimbursement rate for consumer-directed personal care (code S5126) is about $17.97 per hour in Northern Virginia and about $13.88 per hour in the rest of the state, and those figures carry into 2026 unless the budget changes them. That rate is paid to the Fiscal/Employer Agent and covers both the attendant's wage and employer payroll taxes, so the attendant's actual take-home wage is lower, generally in the $13-$16 range in Northern Virginia and around $11-$13 elsewhere. Attendants are W-2 employees, so income tax, Social Security, and Medicare are withheld from each paycheck. Because the exact attendant wage depends on the Fiscal/Employer Agent and the region, ask Public Partnerships (PPL) or Consumer Direct Care Network Virginia for the current per-hour figure before you start.
How long does approval take?
Plan for roughly two to three months, and sometimes longer. The two biggest steps are getting Virginia Medicaid eligibility confirmed and completing the CCC Plus Waiver screening (the Uniform Assessment Instrument, or UAI). If the person is not yet on Medicaid, that application alone can take up to about 90 days. Once eligibility and the level-of-care screening are done, enrolling in a Cardinal Care Managed Care plan and getting set up with a Services Facilitator and Fiscal/Employer Agent usually takes another few weeks. You can move faster by gathering documents in advance: proof of Virginia residency, identification, Social Security number, proof of income and assets, and medical records that show the need for personal care. Starting the Medicaid application and the waiver screening at the same time also saves time.
What training or certification does the attendant need?
None in the clinical sense. This is one of the biggest advantages of the consumer-directed model: the attendant does not need to be a Certified Nursing Assistant (CNA), Home Health Aide (HHA), or any licensed professional. The member (or Employer of Record) trains the attendant on the specific tasks they need, with support from the Services Facilitator. There are basic onboarding requirements handled through the Fiscal/Employer Agent, such as completing federal I-9 and W-4 forms, passing a criminal background check, and reviewing materials on reporting time and recognizing abuse, neglect, or exploitation. But there is no skills exam or licensing test. This makes the program especially welcoming to family members who have been caring for a loved one informally and want that work to finally be paid.
What is the difference between consumer-directed and agency-directed care?
They are two ways to receive the same waiver personal care. In the agency-directed model, a licensed home care agency hires the aide, assigns them to you, sets much of the schedule, and supervises the care. You usually do not choose who shows up. In the consumer-directed (CD) model, you become the employer: you choose the attendant (often a family member or friend you already trust), you train them, you set the schedule, and you can replace them if it is not working. A Services Facilitator supports you and a Fiscal/Employer Agent handles payroll, but neither one supervises the care. Consumer direction gives you the most control and continuity. If you do not have a family member or friend available to hire, agency-directed care may be the better fit.
Who runs the payroll and paperwork for consumer-directed care?
A Fiscal/Employer Agent (F/EA) handles the money side of being an employer. It withholds federal and state taxes, files employment paperwork, and issues the attendant's paychecks. In Virginia, the F/EA is either Public Partnerships LLC (PPL) or Consumer Direct Care Network Virginia (CDCN), and which one you use depends on your Cardinal Care Managed Care plan. Separately, a Services Facilitator helps you and your family understand your responsibilities as the Employer of Record, from writing an emergency backup plan to submitting timesheets correctly. You approve the hours your attendant works each pay period, and the F/EA turns those approved timesheets into a paycheck, typically every two weeks. The F/EA and Services Facilitator are provided at no cost to you as part of the waiver.
Can I live with the person I care for and still be paid?
Yes. There is no rule that prevents an attendant from living in the same home as the person they care for. Many adult children who care for an aging parent, for example, share a household with them and are still paid for the personal care hours they provide. What matters is that you accurately record the hours you actually work providing approved personal care tasks, and that those hours match the plan of care authorized through the UAI assessment. Time spent simply being present in the home, sleeping, or doing your own activities is not paid work. If you are a spouse or the parent of a minor being paid as a Legally Responsible Individual, remember the 40-hour-per-week cap still applies even when you live together.
Does using consumer-directed care change the member's other Medicaid benefits?
No. Choosing the consumer-directed model does not reduce or replace the person's other Virginia Medicaid coverage. They keep their doctor visits, hospital care, prescription drugs, durable medical equipment, and any other covered services. Consumer-directed personal care is simply one part of the CCC Plus Waiver benefit, and it sits alongside the rest of the Medicaid package. If the person is dually eligible for Medicare and Medicaid, Medicare continues to cover acute and short-term skilled care while Medicaid covers the long-term personal care through the waiver. The two programs coordinate through the Cardinal Care Managed Care plan. Switching between agency-directed and consumer-directed care, or changing attendants, also does not affect the rest of the person's benefits.
See also: Virginia caregiver guide
For all the ways to get paid to care for a family member in Virginia — including Cardinal Care CD, VA programs, long-term care insurance, and more — read the full Virginia guide.