Self-direction means the person who receives Medicaid services, or a representative they choose, has authority over the workers and the budget. States also call it participant direction or consumer direction. The support is still waiver or state-plan service. What changes is who hires.
Two patterns are common. In the employer model, the person or representative recruits, schedules, and can dismiss workers. A financial management service handles payroll, taxes, and the budget ledger. In agency-with-choice, a provider agency shares the employer role with the person. The worker may still feel hired by the family. The legal employer may be the agency.
The plan does not go away. An individual support plan still says which services and how many hours are authorized. Self-direction spends that authorization. It does not invent a new one. States differ on whether a parent, spouse, or other relative can be the paid worker, and on how many hours a relative can bill. Those rules move in budget bills more often than the philosophy does.
Families use self-direction when agency shifts are unfilled, or when they want a worker who already knows the person. The risk they describe is the reverse of an agency's risk. The family becomes the scheduler, the trainer, and the one who has to replace a worker who quits. The state still audits the timesheets.
A personal care attendant is the job title you see most often in these arrangements. The work may also be habilitation. The title follows the service on the plan. Calling every self-directed worker a DSP is common in conversation and sloppy on a claim.
Budgets are individual. An unused hour does not automatically move to next month, and an overage is not paid just because the worker showed up. The plan and the fiscal agent's ledger are the two documents that have to agree before a paycheck is real.