A spouse can be paid as a caregiver in Texas in two situations: through the state’s Consumer Managed Personal Attendant Services (CMPAS) program, which is the only Texas Medicaid program that allows spousal pay, or through the U.S. Department of Veterans Affairs’ Program of Comprehensive Assistance for Family Caregivers if the person needing care is an eligible veteran. Outside those two doors, Texas Medicaid waivers explicitly prohibit hiring a spouse, so the pathway you have depends on veteran status and where in the state you live.
Why Most Texas Medicaid Programs Won’t Pay a Spouse
Texas lets Medicaid recipients hire and direct their own caregivers under a model called Consumer Directed Services (CDS). Under CDS, though, a spouse cannot be employed. The rule also bars hiring the recipient’s legally authorized representative or that representative’s spouse.1Texas Health and Human Services. How CDS Works
The same restriction runs through the other major Medicaid-funded home care programs. A spouse cannot be a paid provider under Home and Community-based Services (HCS), Texas Home Living (TxHmL), or Community First Choice (CFC).2Texas Health and Human Services. Update to Temporary Change to HCS and TxHmL Policy for Respite, CFC PAS/HAB Service Providers If your spouse is enrolled in one of these programs, another family member or an outside attendant can be hired, but you cannot be the one on payroll.
The CMPAS Exception
Consumer Managed Personal Attendant Services is the single Texas Medicaid program that permits a spouse to work as the paid attendant. To qualify, the person receiving care must be at least 18, need help with one or more personal care tasks, and require at least five hours of attendant services per week. The recipient — or a friend or relative they designate — has to be willing and able to direct the attendant’s work without extra pay for doing so.3Legal Information Institute. Texas Administrative Code 26-275.25 – Eligibility Criteria
The practical catch is geography. A Medicaid-eligible person living in a STAR+PLUS managed care service area — which covers most of Texas — generally cannot enroll in CMPAS. There is a grandfathering exception: if a spouse was already working as the attendant when STAR+PLUS expanded into that area, the recipient can choose to stay in CMPAS.3Legal Information Institute. Texas Administrative Code 26-275.25 – Eligibility Criteria For most new applicants, CMPAS is not a realistic route to spousal pay.
The VA Pathway for Veteran Families
If your spouse is a veteran, the federal Program of Comprehensive Assistance for Family Caregivers (PCAFC) is a much more accessible option. PCAFC pays a monthly stipend and provides support services to the caregiver of a veteran who incurred or aggravated a serious injury in the line of duty.4eCFR. 38 CFR Part 71 – Caregivers Benefits and Certain Medical Benefits Offered to Family Members of Veterans Since October 2022, the program has been open to veterans of all eras, not only those who served after September 11, 2001.5Veterans Affairs. PCAFC – Reassessment Update
For PCAFC, a “serious injury” means a single service-connected disability rated at 70% or higher, or multiple service-connected disabilities that combine to 70% or higher. The veteran must also need personal care services because of an inability to perform activities of daily living or a need for supervision, protection, or instruction.4eCFR. 38 CFR Part 71 – Caregivers Benefits and Certain Medical Benefits Offered to Family Members of Veterans
How the Stipend Is Calculated
The monthly stipend uses the federal General Schedule pay rate for a GS-4, Step 1 position in the locality where the veteran lives, divided by 12. That number is then multiplied by a tier percentage:4eCFR. 38 CFR Part 71 – Caregivers Benefits and Certain Medical Benefits Offered to Family Members of Veterans
- Tier 1, a 0.625 multiplier, for veterans who need personal care services but can sustain themselves in the community with support.
- Tier 2, a 1.0 multiplier, for veterans the VA finds unable to sustain themselves in the community.
Because GS pay varies by locality, stipends differ across Texas. Using 2022 figures for the Dallas area, Tier 1 came out to roughly $1,819 per month and Tier 2 to roughly $2,910 per month. Current amounts are higher due to annual pay adjustments.
What Comes With the Stipend
A designated Primary Family Caregiver also receives at least 30 days of respite care each year, giving you time off while someone else covers the veteran’s needs.6Veterans Affairs. The Program of Comprehensive Assistance for Family Caregivers A caregiver spouse who has no other health insurance may qualify for CHAMPVA coverage when the veteran is rated permanently and totally disabled.7Veterans Affairs. CHAMPVA Benefits
Setting Up the Arrangement
For a Medicaid attendant services application in Texas, the core clinical document is Form 3052, the Practitioner’s Statement of Medical Need.8Texas Health and Human Services. Form 3052, Practitioner’s Statement of Medical Need A licensed physician or other qualified practitioner completes it to certify that the applicant has a medical diagnosis producing at least one functional limitation, such as difficulty with mobility, bathing, or eating.9Texas Health and Human Services. 4600, Primary Home Care and Community Attendant Services The practitioner has to include their license number, National Provider Identifier, and contact information; incomplete forms are returned.
Once approved, the recipient works with a Financial Management Services Agency (FMSA), which registers with the IRS as the employer’s agent, runs payroll, and handles tax withholdings. The attendant, including a spouse hired through CMPAS, must clear a criminal background check before starting work.1Texas Health and Human Services. How CDS Works Wages are set within the recipient’s allocated budget. As of September 1, 2025, STAR+PLUS reimbursement rates are structured to support an average attendant wage of $13.00 per hour, plus payroll taxes and benefits.10Texas Health and Human Services. STAR+PLUS Rates – September 1, 2025
For PCAFC, the veteran and prospective caregiver both complete VA Form 10-10CG, either online or by mail.11Veterans Affairs. Apply for the Program of Comprehensive Assistance for Family Caregivers The VA then schedules a clinical evaluation of the veteran’s daily care needs before designating the caregiver.
One planning point applies to any family caregiving arrangement tied to Medicaid: if the recipient later applies for Medicaid long-term care, the state reviews the previous five years of financial transactions. Payments to a family caregiver without a written care agreement in place can be flagged as a prohibited transfer, so put the arrangement in writing before money changes hands.
How Caregiver Pay Is Taxed
A spouse paid through a Medicaid Home and Community-Based Services waiver may be able to exclude those wages from federal gross income under IRS Notice 2014-7. The payments qualify as “difficulty of care” payments when the caregiver and the care recipient share the same home — meaning the home is where the caregiver actually lives and carries out ordinary daily life, including meals, holidays, and family activities.12Internal Revenue Service. Certain Medicaid Waiver Payments May Be Excludable From Income
If the caregiver keeps a separate residence where they regularly live, the exclusion does not apply, even if they spend significant time at the recipient’s home. Vacation pay from the state is not excludable either. More than one caregiver living with the recipient can each exclude their waiver payments.12Internal Revenue Service. Certain Medicaid Waiver Payments May Be Excludable From Income
Separately, wages paid to a spouse are generally not subject to Social Security, Medicare (FICA), or federal unemployment (FUTA) tax. So when a Medicaid recipient directly employs their spouse in a consumer-directed arrangement, the usual payroll tax withholdings typically do not apply.13Internal Revenue Service. Tax Situations When Taking Care of a Family Member
If You Receive SSI, Do the Math First
If you receive Supplemental Security Income, caregiving wages count as earned income and can reduce your monthly SSI. SSI does not count every dollar, though. The first $65 of monthly earnings — plus any unused portion of the $20 general income exclusion — is disregarded, and only half of what remains counts against your benefit.14Social Security Administration. Income Exclusions for SSI Program A spouse earning $500 a month as a caregiver would see less than $500 knocked off SSI because of those exclusions. Run the numbers before accepting paid hours if SSI is part of your household income.
Appealing a Denial
If Texas denies your application for Medicaid-funded caregiver services or reduces your approved hours, you can request a fair hearing. You have 90 days from the date on the denial notice to file. When the action came from a managed care organization, as it typically does under STAR+PLUS, you have 120 days after the MCO completes its internal appeal process.15Texas Health and Human Services. FFHH Frequently Asked Questions – Client Appeals can go in by phone, fax, mail, or in person at a local office, and missing the deadline is not automatically fatal — you can still request a hearing if you show good cause. Depending on the program and when you file, benefits may continue while the appeal is decided.