New York CDPAP: How Families Turn Medicaid Home Care Hours into Caregiver Income

Once a family navigates the financial hurdles of Medicaid eligibility—utilizing a Pooled Income Trust to resolve surplus monthly income and a Medicaid Asset Protection Trust (MAPT) to insulate life savings—they encounter the next critical question:

Who will actually provide the daily care?

In New York City, many aging seniors are uncomfortable with strangers entering their homes. Simultaneously, adult children and family members frequently find themselves cutting back work hours, leaving careers, or exhausting their own savings to care for an aging parent without pay.

The Consumer Directed Personal Assistance Program (CDPAP) is a New York Medicaid program designed to bridge this divide. Under CDPAP, eligible seniors recruit, hire, and direct their own caregivers—and those caregivers, including adult children, are paid legal hourly wages funded by New York Medicaid.

This guide breaks down how CDPAP works under New York law, who can (and cannot) be hired as a paid caregiver, wage rates and tax rules, and the step-by-step enrollment process.

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1. What Is CDPAP?

Authorized under (New York Social Services Law § 365-f) and governed by (18 NYCRR § 505.28), the Consumer Directed Personal Assistance Program (CDPAP) is an alternative to traditional, agency-directed home care.

In standard home care, a licensed home care services agency (LHCSA) assigns certified Home Health Aides (HHAs) or Personal Care Aides (PCAs) on schedules determined by the agency.

Under CDPAP, the senior (the "Consumer") acts as the legal managing employer. They have the statutory authority to recruit, hire, train, schedule, and, if necessary, dismiss their own caregivers (officially designated as Personal Assistants).

                      ┌────────────────────────┐
                      │  New York Medicaid /   │
                      │       MLTC Plan        │
                      └───────────┬────────────┘
                                  │  Authorizes Hours & Funds
                                  ▼
                      ┌────────────────────────┐
                      │  Fiscal Intermediary   │
                      │         (FI)           │
                      └─────┬────────────┬─────┘
  Processes Payroll / Taxes │            │ Confirms Timesheets / EVV
                            ▼            ▼
┌──────────────────────────────┐      ┌──────────────────────────────┐
│      Personal Assistant      │◄────►│           Consumer           │
│  (Adult Child / Caregiver)   │      │ (Senior or Designated Rep.)  │
│    Receives Hourly Wages     │      │ Hires, Trains, & Directs Care│
└──────────────────────────────┘      └──────────────────────────────┘

The Three Key Roles:

1. The Consumer: The Medicaid recipient receiving care. If the consumer has cognitive impairments (such as advanced Alzheimer’s or dementia), an appointed Designated Representative (often an adult child) makes management decisions on their behalf.
2. The Personal Assistant (PA): The person hired to provide the hands-on care (e.g., an adult child, relative, or trusted friend).
3. The Fiscal Intermediary (FI): An entity contracted to process payroll, withhold taxes, administer statutory benefits, and verify compliance with state labor standards.

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2. CDPAP vs. Traditional Agency Home Care

The structural difference between CDPAP and standard agency care extends beyond who provides the service: it directly affects the scope of clinical tasks a caregiver is legally allowed to perform.

Feature	Traditional Agency Care (LHCSA)	CDPAP (Consumer Directed)
Governing Statute	NY Public Health Law Article 36	NY Social Services Law § 365-f
Caregiver Identity	Agency-employed HHA/PCA (usually assigned).	Family member, friend, or trusted hire chosen by consumer.
Hiring & Scheduling	Dictated by agency availability.	100% controlled by the consumer and family.
Certification Required	Yes (Must complete NY State HHA/PCA training).	No state certification or license required.
Skilled Nursing Tasks	Strictly Prohibited. Aides cannot administer meds, give injections, or touch sterile dressings.	Allowed only when included in the approved plan of care and the Personal Assistant is trained under consumer direction.
Backup Coverage	Agency is responsible for sending a substitute aide.	Family/consumer is responsible for coordinating backup care.

The Skilled Nursing Exception: A Critical Advantage

Under the New York Nurse Practice Act (New York Education Law § 6908(1)(a)(iv)), Personal Assistants operating under CDPAP are legally exempt from nurse licensing rules.

In a traditional agency setting, an aide cannot administer insulin injections, manage a ventilator, clean a tracheostomy tube, or administer prescription eye drops; a Registered Nurse (RN) must be dispatched at significant expense. Under CDPAP, because the consumer or their designated representative trains the assistant, the Personal Assistant can legally perform these skilled nursing tasks.

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3. Who Can (and Cannot) Be Hired as a Personal Assistant?

New York allows a broad circle of individuals to be hired and paid under CDPAP, but maintains strict statutory prohibitions regarding legally responsible parties.

================================================================================
                         CDPAP ELIGIBILITY MATRIX
================================================================================

[ CAN BE HIRED AND PAID ]                 [ STRICTLY PROHIBITED BY LAW ]
--------------------------------------------------------------------------------
✔ Adult Children (over 18)                 ✖ Legal Spouse of the Consumer
✔ Grandchildren                            ✖ Parent caring for a child under 21
✔ Siblings                                 ✖ The Consumer's Designated Representative
✔ Nieces, Nephews, Cousins                 ✖ Anyone under the age of 18
✔ Friends and Neighbors                    ✖ An individual without legal US work status
✔ Parents (ONLY if consumer is 21+)
================================================================================

The "Designated Representative" Conflict of Interest

Crucial Rule: Under (18 NYCRR § 505.28(h)(2)), an individual cannot serve as both the Designated Representative and the paid Personal Assistant.

If a parent has advanced dementia and cannot manage their own care, one adult child (e.g., the daughter) can serve as the Designated Representative directing the care, while a second adult child (e.g., the son) is hired as the paid Personal Assistant. Alternatively, if the parent remains mentally competent, they act as their own representative, allowing any adult child to be hired.

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4. Caregiver Compensation: Wages, Hours, and Tax Exemptions

Personal Assistants are W-2 employees of the Fiscal Intermediary, paid with Medicaid funds authorized by the consumer's Managed Long-Term Care (MLTC) plan or local Department of Social Services.

1. Hourly Pay Rates in New York City

Caregiver wage minimums in New York are governed by state minimum wage rules and the Home Care Worker Wage Parity Act (New York Public Health Law § 3614-c).

• NYC, Long Island, and Westchester: Baseline hourly pay rates typically range from $18.55 to $21.09 per hour, depending on the Fiscal Intermediary’s supplemental benefit package (health benefits, paid time off, transit allowances).
• Rest of New York State: Rates generally range from $17.55 to $19.00 per hour.

2. Overtime and Hour Caps

While New York Medicaid authorizes a specific number of weekly hours based on clinical need (up to 24/7 or continuous split-shift care in documented cases), many Fiscal Intermediaries cap individual caregivers at 40 hours per week to limit overtime liabilities under the Fair Labor Standards Act. When a senior is approved for 50, 60, or more weekly hours, the family typically onboards two or more assistants to share the authorized schedule.

3. The Live-In Tax Advantage: IRS Notice 2014-7

If a Personal Assistant lives in the same household as the care recipient, their CDPAP earnings may be completely exempt from federal and New York State income taxes.

Under (Internal Revenue Code § 131) and IRS Notice 2014-7, Medicaid waiver payments received by an individual providing care to a care recipient living in their home are classified as "Difficulty of Care" payments. Caregivers who qualify can exclude these wages from gross income on Form 1040, dramatically increasing their effective take-home pay.

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5. State Policy Shifts: The Transition to a Single Statewide FI

For years, hundreds of independent Fiscal Intermediaries operated across New York. To curb state spending and streamline administrative oversight, the New York State Fiscal Year 2024–2025 Executive Budget amended (New York Social Services Law § 365-f(4-a)), directing the New York State Department of Health (DOH) to replace the multi-FI system with a single Statewide Fiscal Intermediary contracted through a primary vendor.

What This Means for Families:

• Continuity of Care: The program itself has not been eliminated. Consumers retain the legal right to hire and direct family caregivers.
• Administrative Migration: Personal Assistants and consumers across New York are transitioning to the state-selected vendor for time tracking, onboarding, and payroll processing.
• Electronic Visit Verification (EVV): Caregivers must log hours electronically via an approved EVV smartphone app or landline telephony system, as mandated by Section 12006 of the federal 21st Century Cures Act (42 U.S.C. § 1396u-7).

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6. Step-by-Step Guide: How to Enroll in NY CDPAP

Step 1: Secure New York Community Medicaid Approval
Step 2: Request the NYA Independent Clinical Assessment
Step 3: Obtain Physician Order (Form DOH-4359)
Step 4: Select an MLTC Plan & Determine Authorized Hours
Step 5: Designate Representative & Select Fiscal Intermediary
Step 6: Complete Personal Assistant Onboarding & Begin Care

Step 1: Secure Community Medicaid Eligibility

Ensure the senior is actively enrolled in New York Community Medicaid. If excess income or capital resources exist, establish a Pooled Income Trust for surplus monthly earnings and a MAPT or Spousal Refusal strategy to protect assets.

Step 2: Schedule the NYA Clinical Assessment

All long-term home care evaluations in New York are initiated through the New York Independent Assessor (NYA). A conflict-free Registered Nurse completes a clinical assessment using the Community Health Assessment (CHA) tool to evaluate the senior's limitations with Activities of Daily Living (ADLs) such as bathing, dressing, transferring, and toileting.

Step 3: Complete the Physician Medical Order (Form DOH-4359)

The senior's primary care physician must complete and sign the Physician Medical Order Form (Form DOH-4359), documenting that the individual is medically stable and capable of receiving long-term home care safely in a community setting.

Step 4: MLTC Plan Enrollment and Plan of Care

Once clinical eligibility is confirmed, the family selects a Managed Long-Term Care (MLTC) plan. The MLTC care manager conducts a final home assessment to establish the official Plan of Care, which defines the exact number of weekly authorized hours. Inform the care manager immediately that you intend to use the CDPAP option.

Step 5: Onboard the Personal Assistant with the FI

The family-selected caregiver registers with the designated Fiscal Intermediary. The onboarding packet includes:

• Form I-9 verifying legal authorization to work in the United States.
• Direct deposit banking authorization.
• Mandatory medical clearance: physical exam, current Tuberculosis (PPD/QuantiFERON) screening, and proof of Rubella/Rubeola immunity, pursuant to (10 NYCRR § 766.11).

Step 6: Begin Service and Time Tracking

Once cleared by the FI, the caregiver begins working shifts. Every shift is logged via the state-compliant Electronic Visit Verification (EVV) system, and payments are issued weekly or bi-weekly via direct deposit.

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7. Common Pitfalls to Avoid

• Naming the Paid Caregiver as the Designated Representative: If the senior lacks cognitive capacity, the person signing state agreements as the designated representative cannot receive wages. Establish an alternate family member as the representative before submitting paperwork.
• Failing Electronic Visit Verification (EVV) Protocols: New York strictly audits caregiver time and attendance. Personal Assistants who fail to clock in and out using the designated mobile application or toll-free landline telephony can face payroll delays and state compliance audits.
• Exceeding Authorized Hours Without Plan Approval: A caregiver cannot bill for more hours than authorized in the MLTC Plan of Care. If the senior’s condition deteriorates and requires additional support, the family must request a formal reassessment from the MLTC.
• Neglecting Backup Care Planning: Under CDPAP regulations, the consumer is responsible for arranging emergency coverage if the primary family caregiver falls ill or cannot work a shift.

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Summary Checklist

Action Item	Responsible Party	Legal / Administrative Mandate	Status
Verify Medicaid Eligibility	Family / Care Coordinator	Ensure active Community Medicaid via spend-down clearance.	[ ]
Schedule NYA Assessment	NY Independent Assessor / RN	Complete Community Health Assessment (CHA).	[ ]
Secure Physician Order	Primary Care Physician	Execute Form DOH-4359 verifying home care stability.	[ ]
Establish Plan of Care	MLTC Plan Care Manager	Authorize weekly hours under 18 NYCRR § 505.28.	[ ]
Appoint Representative	Family (if consumer is impaired)	Designate managing representative (cannot be the paid aide).	[ ]
Complete PA Medicals	Personal Assistant / Physician	Complete physical exam and TB test under 10 NYCRR § 766.11.	[ ]
Setup EVV Account	Personal Assistant / FI	Install compliant EVV app under 42 U.S.C. § 1396u-7.	[ ]

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Disclaimer: This guide is prepared by the NurseNow editorial team for educational and informational purposes only. Medicaid rules, Fiscal Intermediary structures, and wage parity mandates are subject to frequent administrative updates by the New York State Department of Health. NurseNow is not a licensed home care services agency, fiscal intermediary, or legal entity. Families should consult with an accredited Medicaid coordinator or elder care professional to review their clinical and financial eligibility.