In Texas, a spouse can be paid as a caregiver through Medicaid in only one program: Client Managed Personal Attendant Services, known as CMPAS. Every other Medicaid-funded attendant program in the state, including STAR+PLUS Home and Community-Based Services and Community First Choice, specifically prohibits hiring a husband or wife as a paid attendant, even when the program otherwise lets the care recipient choose their own worker.
Why Most Texas Medicaid Programs Will Not Pay a Spouse
Texas uses a Consumer Directed Services (CDS) model in several Medicaid programs, which lets the person receiving care hire, train, and supervise their own attendant under Texas Government Code ยง 531.051.1Texas Public Law. Texas Government Code Section 531.051 – Consumer Direction of Certain Services for Persons with Disabilities That flexibility is wide, but it stops at the spouse. The official CDS guidance says “the spouse of the person receiving services, or the employer’s spouse” cannot be hired as a CDS employee, with CMPAS named as the only exception.2Texas Health and Human Services. Consumer Directed Services Option Frequently Asked Questions The Community First Choice state plan carries the same bar: a recipient’s spouse cannot provide personal assistance services under either the agency model or the consumer-directed model.3Medicaid.gov. Texas Community First Choice Eligibility Pathways
Other relatives are not swept into this restriction. Adult children, grandchildren, siblings, parents, and extended family can be hired as paid attendants under STAR+PLUS or Community First Choice. The exclusion is targeted at the spouse specifically, and it is often the first surprise families run into when they look at the CDS option.
The One Program That Allows a Spouse: CMPAS
CMPAS is built around the idea that the person receiving care manages the attendant directly, choosing who provides help and how. It is the only Texas Medicaid program in which that attendant can be the recipient’s spouse.4Texas Health and Human Services. Consumer Managed Personal Attendant Services Provider Manual
To qualify, the person receiving the care must:
- Be at least 18 years old.
- Have a physical disability certified by a physician as permanent or expected to last at least six months.
- Need help with at least one personal care task such as bathing, dressing, grooming, mobility, toileting, or meal preparation.
- Require at least five hours per week of personal attendant services.
- Be mentally and emotionally capable of directing their own attendant care, or have a relative or friend willing to share that responsibility.
- Live in a designated CMPAS service area. The program is not available statewide.
The self-direction piece matters. CMPAS expects the recipient to interview, hire, train, supervise, and if necessary dismiss their own attendant. A licensed home health agency handles administrative work and payroll, but the recipient keeps authority over the day-to-day caregiving relationship. Someone who cannot participate in those decisions, for cognitive or other reasons, needs a relative or friend willing to share that direction role.
CMPAS also will not stack with certain other services. A recipient cannot be enrolled in Primary Home Care, Community Based Alternatives, Family Care, Assisted Living, or Adult Foster Care at the same time.4Texas Health and Human Services. Consumer Managed Personal Attendant Services Provider Manual If the care recipient is currently receiving one of those, something has to change before CMPAS can begin.
Standard Texas Medicaid financial rules still apply to the recipient: income at or below 300% of the SSI federal benefit rate, and resource limits of $2,000 for an individual.5Cornell Law School Legal Information Institute. 1 Texas Admin Code 358.433 – Special Income Limit6Texas Health and Human Services. MEPD and TW Bulletin 25-24 Only the recipient’s income is counted, not the working spouse’s.
What the Spouse Has to Clear Before Starting Paid Work
Qualifying the care recipient is only half the picture. The spouse who will be paid has to meet a short list of worker requirements.
Age and Background Check
The spouse must be at least 18. Before any hire, the contracting agency has to search the Employee Misconduct Registry and the Nurse Aide Registry to confirm there are no findings of abuse, neglect, exploitation, or misconduct against a care recipient.7Texas Health and Human Services. Employee Misconduct Registry A criminal history check is also required, and certain convictions permanently disqualify a person from paid caregiving. Fingerprinting and background check fees typically run $37 to $40.
Training
Under CMPAS, the care recipient is responsible for training their own attendant on the specific tasks they need help with, and for making sure each task is performed safely.
Electronic Visit Verification
Federal law requires Electronic Visit Verification (EVV) for all Medicaid-funded personal care services, and Texas has enforced it since January 2021.8Texas Health and Human Services. Electronic Visit Verification EVV records when a visit starts and ends, the type of service, and the location. The spouse working as the attendant clocks in at the start of each shift and clocks out at the end using an approved method. For the CDS model, the employer must also complete EVV Policy Training and EVV System Training each year.9Texas Health and Human Services. EVV Consumer Directed Services Option Hours that are not properly verified can go unpaid, so this is not an area to be casual about.
Taxes on the Caregiving Pay
Three federal provisions make the tax picture unusually favorable for a spouse paid as a household caregiver.
Wages a household employer pays to a spouse are exempt from Social Security and Medicare taxes (FICA), on both the employee and employer side.10Internal Revenue Service. Publication 926 (2026), Household Employer’s Tax Guide Those wages are also excluded from federal unemployment tax (FUTA).11Internal Revenue Service. Topic No. 756, Employment Taxes for Household Employees
The biggest item is IRS Notice 2014-7. It lets certain Medicaid waiver payments be excluded from gross income entirely when the caregiver lives in the same home as the care recipient, treating the payments as “difficulty of care” payments under Section 131 of the Internal Revenue Code.12Internal Revenue Service. Certain Medicaid Waiver Payments May Be Excludable From Income For married couples living together, that exclusion almost always applies, and many spousal caregivers end up owing no federal income tax on their caregiving wages. Keep copies of every pay statement in case the exclusion is ever questioned.
How to Apply
Start by contacting your local Texas Health and Human Services office. An intake specialist runs an initial screening, and the state then schedules an in-home assessment to evaluate what help the recipient needs. The recipient also selects a licensed home health agency to handle payroll and administrative duties under CMPAS.13Texas Health and Human Services. How CDS Works
Have these ready before you apply:
- Bank statements, Social Security award letters, life insurance policies, and property deeds for the recipient.
- Medical records documenting the disability and its expected duration.
- A physician’s statement confirming a permanent physical disability or one expected to last at least six months. This is a core CMPAS requirement.
Form H2060, the Needs Assessment Questionnaire and Task/Hour Guide, is used during the assessment to translate the recipient’s difficulty with daily tasks into authorized weekly hours.14Texas Health and Human Services. Form H2060, Needs Assessment Questionnaire and Task/Hour Guide
Processing deadlines are set by rule. Texas HHS must decide eligibility within 45 days if the applicant is age 65 or older or already has an established disability determination. If a new disability determination is needed through the HHSC Disability Determination Unit, the clock runs 90 days.15Texas Health and Human Services. B-6400, Processing Deadlines Incomplete paperwork is the usual reason for delay, so submit everything at once rather than in pieces.
If the Application Is Denied
If the state denies the application or reduces authorized services, the recipient has the right to request a fair hearing. The deadline is 90 calendar days from the effective date of the adverse action or from the date of the denial notice, whichever is later. The request can be made in writing or orally, and no specific form is required. For denials that come through a managed care organization, the window is 120 days from the MCO’s final determination.16Texas Health and Human Services. 1400, Submitting a Fair Hearing Request Summary
Filing early matters. If the appeal is submitted before the effective date of the action, services may be able to continue while the hearing is pending. Waiting until day 89 usually means services lapse in the interim.
Estate Recovery and the Surviving Spouse
One concern that comes up often: will the state try to recoup caregiving costs after the Medicaid recipient dies? Texas does operate a Medicaid Estate Recovery Program, but it will not seek reimbursement from a Medicaid recipient’s estate while a surviving spouse is still alive.17Texas Health and Human Services. Your Guide to the Medicaid Estate Recovery Program For a spouse who provided the care, that protection is the one that matters most.