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Structured Family Caregiving (SFC) Service Definition PROPOSAL
Service Definition (Scope)
Structured Family Caregiving (SFC) is a shared living Medicaid waiver service that enables participants to remain safely in their community by supporting dedicated caregivers who provide daily, non-medical care in a home setting. This person-centered approach preserves dignity and independence while preventing unnecessary institutionalization.
The participant receives individualized care in a home setting of their choice while the Principal Caregiver (family or non-family member) provides daily care and receives financial support, training, and ongoing assistance. The SFC Provider Agency serves as the Medicaid provider, ensuring quality, compliance, and monitoring the caregiving relationship. A key component of this model is the Caregiver Coach, a professional from the agency who provides the Principal Caregiver with financial support, personalized training, and consistent, ongoing assistance. The Caregiver Coach is responsible for monitoring the caregiving relationship to ensure the well-being of both the participant and the caregiver.
This service preserves participant dignity while also protecting caregiver sustainability through structured support and expert coaching.
Goals of the Service
Ease the economic pressure on caregivers with financial support, allowing them to focus on the participant's needs.
Strengthen natural caregiver networks to reduce reliance on institutional long-term care.
Empower caregivers with individualized training, coaching, and resources to sustain their role.
Promote continuity of care through trusted, established relationships.
Ensure participants can remain in a culturally competent, person-centered environment of their choice.
Promote the participant’s independence and dignity in a setting that protects their choice and self-respect.
Expand the availability of community-based long-term services and supports (LTSS).
SERVICE LEVELS
There are three levels of SFC, each with a unique per diem rate. The applicable rate is determined by completion of the SFC/Adult Family Care Level of Service Assessment. The assessment is completed annually to reflect the intensity of caregiver support needs:
Level 1 – AFC/SFC LOS Assessment Score of 0 - 35.
Level 2 – AFC/SFC LOS Assessment Score of 36 - 60.
Level 3 – AFC/SFC LOS Assessment Score of 61+
REIMBURSABLE ACTIVITIES
Personal Care: Assistance with ADLs such as bathing, dressing, grooming, and mobility.
Medication Management: Only to the extent permitted under state law (e.g., reminders, cueing, or directed assistance).
Ongoing oversight: Continuous awareness of participant location and activities
Cueing and redirection: Prompting for safety, routine tasks, and behavioral support
Instrumental Activities of Daily Living (IADLs): Assistance with meal preparation, light housekeeping, laundry, shopping, financial management, and phone use.
Technology support: Assistance with communication devices, telehealth, and social connections
Companionship & Community Inclusion: Social engagement and participation in community activities.
Transportation Services: Escorting for necessary appointments, whenever possible, such as transporting individuals to doctor. When provided, such transportation is incidental and not duplicative of any other State Plan or waiver service. Support by a substitute caregiver who has met all principal caregiver qualifications.
Substitute and Backup Care: Provide temporary care through qualified substitute caregivers to support respite, cover emergencies or caregiver illness, and coordinate care during planned absences such as vacations or personal needs.
Other appropriate supports as described in the individual’s service plan.
SERVICE STANDARDS
Waiver Case Manager Responsibilities
Assessment & Service Planning: The case manager identifies the participant's initial need for Structured Family Caregiving and conducts annual reassessments to confirm ongoing needs and eligibility.
Define Services: The service plan must clearly outline the specific services and support that the principal caregiver will be providing.
Care Plan Development: The case manager facilitates the initial development of the person-centered Care Plan and is responsible for coordinating all subsequent updates as the participant's needs change.
Caregiver Assessment: Administer caregiver assessment and review the findings to verify the caregiver is capable of meeting the participant's needs.
Deliver Documentation: Once complete, the case manager is responsible for giving both the final service plan and the Caregiver Assessment to the chosen Structured Family Caregiving provider agency. When a participant transfers between agencies, the case manager must also inform the new agency of the participant’s remaining respite day balance for the current service year.
Principal Caregiver Responsibilities
Caregiver Residency: The principal caregiver must reside full-time in the same home as the participant.
Home Environment: The living arrangement must preserve all rights and dignity of a private residence, including privacy, comfortable surroundings, and the opportunity for the participant to personalize their living space.
Care Plan Adherence: Provide all support as identified in the participant’s individualized Care Plan/Service Plan.
Documentation & Incident Reporting: Keep accurate, factual daily records of care and complete all other reporting requirements set by the provider agency or BDS.
Collaborate with the Care Team: Participate in care planning meetings and team conferences, sharing observations and feedback.
Training & Communication: Complete all required training and maintain ongoing communication with the agency, providing updates on participant needs or changes in a timely manner.
Emergency Preparedness: Create an emergency care plan with the SFC agency, maintain up-to-date emergency contact information, and follow all incident reporting protocols.
SFC Provider Agency Responsibilities:
Credentialing, Compliance, and Documentation Oversight: Ensure the principal caregiver meets all qualifications, maintains ongoing compliance with agency and waiver requirements, and that all required caregiver documentation is accurate, complete, and properly maintained.
Caregiver Development and Training: Use the Case Manager’s Caregiver Assessment to identify training needs, provide ongoing support, and track progress. Deliver initial and continuing training tailored to lay caregivers to ensure they are equipped to provide quality care.
Home Safety Assessments: Evaluating the home for accessibility and safety.
Emergency Care Plan: Develop and monitor an emergency care plan that identifies backup caregivers and outlines procedures for potential absences or emergencies.
Communication & Visits: The provider agency must maintain regular contact with caregivers to offer guidance, review the participant's status, and provide ongoing support. This includes conducting a minimum of two check-in visits per quarter, with at least one being an in-person home visit. Additional visits will be scheduled based on the caregiver’s needs.
Incident Management & Collaboration: The agency is responsible for managing the entire process for all reportable incidents, including investigation and follow-up. All communication and collaboration with the Case Manager regarding these events must be documented.
Stipend Administration: Issuing daily stipends to the caregiver, with at least 60% of the Medicaid per diem rate allocated directly to the caregiver.
Respite Support: Ensure access to substitute caregivers for up to 15 days of respite per year
Caregiver Coach Requirements: The SFC provider agency must employ or contract a caregiver coach to provide caregiver training and support that meets the following requirements:
A. Education/Credentials (one required):
Bachelor's degree in any field
Associate's degree in social work, nursing, human services, or related field
High school diploma/GED plus professional certification such as CNA, HHA, QMA, or CHW
B. Experience (one required):
Professional Track: 2+ years working with vulnerable populations in professional capacity
Personal Experience Track: 3+ years as primary caregiver for person with disability, chronic illness, or aging-related needs
Peer Experience Track: 1+ year peer support, advocacy, or mentoring others
C. Parents of minor participants and spouses are not eligible to serve as caregiver coaches.
Caregiver Training Requirements: The Caregiver Coach must conduct all required training according to the following schedule.
Initial Training: Prior to starting services caregivers must complete all of the floowing:
Core Competencies: Either agency training in the BDS core competencies, successfully pass the Home and Community Support Professional (HCSP) Training Program, or be listed on the HCSP Registry, and must be CPR certified.
Participant Needs: Caregivers must be trained in recognizing and responding to the participant's needs—physical, social, emotional, and behavioral.
Safety Certifications: Caregivers must hold current CPR and First Aid certifications that include an in-person skills assessment.
Ongoing Training: Caregivers must complete a minimum of 8 hours of continuing education each year, beginning on the caregiver’s official date of hire and renewing annually thereafter.
Training Topics: Training may include, but is not limited to, the following areas:
Safety & Emergency Preparedness (core safety, fall prevention, good body mechanics, safe transfers, transportation safety)
Infection Control & Hygiene (personal care, bathing, grooming, adaptive feeding if applicable)
Nutrition & Meal Support (basic nutrition, special diets, choking risk foods)
Person-Centered Care (dignity of risk, behavioral & emotional support, positive behavioral supports, de-escalation strategies)
Communication & Cultural Competency (effective communication with individuals with disabilities, cultural sensitivity)
Privacy & Documentation (HIPAA, care planning, daily documentation, compliance)
Adaptive Equipment & Home Safety (wheelchairs, lifts, bed rails, household organization)
Stress Management for Caregivers
Autism & Developmental Disability Support Strategies
Dementia-Specific Training (if applicable): understanding dementia, behavioral and psychosocial symptom management, decision-making capacity, and advanced care planning
6. Respite Services
Billed Respite is a formal service where the substitute caregiver is employed and paid directly by the provider agency. The agency then bills Medicaid for the service day. The principal caregiver does not receive their daily stipend for the days that the SFC agency provides respite care.
Unbilled Respite is an informal arrangement where a friend or family member chosen by the participant provides temporary care. No compensation is provided, the agency does not bill Medicaid for the service day, and the principal caregiver does not receive their daily payment.
Stipend Redirection Respite: is an option available only when the substitute caregiver resides full-time in the same home as the participant. During the respite period, the agency redirects the daily payment to the qualified, co-habitating substitute caregiver. The principal caregiver does not receive a payment for these days. The substitute caregiver must meet all agency requirements, including training and compliance with Structured Family Caregiving policies.
Entitlement: Each participant is entitled to up to 15 days of respite per service year. The agency is responsible for ensuring this entitlement is met, either by providing the respite directly or coordinating with an appropriate alternative provider.
Planning & Documentation: Timing, duration, and format of respite service blocks must be agreed upon at enrollment and documented in the participant’s file. Participant preferences and desired arrangements must be recorded and reviewed regularly.
Accountability & Tracking: The agency remains responsible for ensuring respite is delivered or coordinated according to the participant’s plan, including when an external provider is used. Records must include date, duration, and caregiver providing the service.
Flexibility: Respite may be used consecutively or intermittently. The agency may adjust scheduling or duration based on participant needs, staffing, and program requirements.
DOCUMENTATATION STANDARDS
Each quarter (or more often as determined by the individual's circle of support), the service provider must prepare a progress report and provide this report to the case manager. The case manager will upload the progress report to the document library of the individual in the state's case management system on or before the 15th day of the month following the end of the reporting period. The first reporting period must align with the start of the individual's service plan.
The progress report must include:
o Name of the individual served
o IHCP Member ID (RID) of the individual served
o Service rendered
o Date range of services rendered
o Notation of the ratio for service delivery (if ratio other than 1 staff to 1 individual being served)
o Name of the provider (and title if applicable)
o Brief summary of progress towards service plan outcomes
o Challenges hindering progress towards service plan outcomes, if applicable
o A positive event that occurred during the reporting period that contributed to the individual's good life
The provider must maintain all documentation required under 455 IAC 2, plus the following records:
Accessibility: Upon request, all documentation must be made available to auditors, quality monitors, case managers and any other government entity he provider agency. Records may be stored in multiple locations, but they must be clearly organized and easily linked to the individual to meet compliance standards.
Qualifications & Training: All caregiver credentialing documentation, qualifications, and training certificates must be maintained in the employee file.
Schedules & Attendance: Records of caregiver schedules and attendance logs.
Safety Checks: Completed forms for environmental and equipment safety checks.
Daily Caregiver Notes: Daily notes documenting non-medical assistance (ADLs/IADLs), supervision provided, and any observed changes in the participant's condition.
Care Plan Compliance: Evidence that services are being delivered in accordance with the Care Plan, including any documented adjustments.
Incident Reports: All incident reports and documentation of follow-up actions taken.
Quarterly Visits & Coaching: Documentation of quarterly home visits, caregiver coaching sessions, wellness planning, and any use of substitute caregivers.
Communication Logs: Records of communication with the participant, family, waiver case managers, and other care team members.
Case Manager Collaboration: Evidence of collaboration with case managers, focusing on non-medical updates and resource navigation.
The principal caregiver must document the following relevant data elements for each service day:
o Services provided: Specific ADLs, IADLs, and supervision assistance completed
o Participant engagement: Activities, social interactions, and community participation
o Health and well-being observations: Mood, energy level, appetite, and notable changes
o Safety concerns: Environmental hazards, incidents, or risk factors
o Communication: Interactions with family, healthcare providers, or care team
o Notable events: Appointments, visitors, community activities, or special circumstances
o Standards: Documentation must focus on observable behaviors and measurable outcomes
SPECIAL CONSIDERATIONS:
Billing Conditions: The SFC agency may bill Medicaid on days when either the principal caregiver provides in-person care or care is provided by a Qualified Substitute Caregiver. A Qualified Substitute Caregiver is an individual whose credentials, training, and background have been verified by the agency, confirming their eligibility to provide compliant services under the waiver.
Daily Stipend Structure: Agencies receive a per diem payment from Medicaid and must pass a minimum of 60% directly to the caregiver as a tax-free stipend.
Principal Caregiver Compensation: Receives the daily stipend for any day they provide in-person care or supervise care provided by a Qualified Substitute Caregiver. Stipends are issued directly by the agency and are tax-free to the extent allowed under state law.
Qualified Substitute Caregiver (Live-In or Temporary) Compensation: When providing approved care, substitute caregivers who meet agency qualifications may receive payment either as a stipend (for live-in arrangements where the principal caregiver’s stipend is redirected) or as a W-2/1099 employee through the agency, depending on the employment arrangement.
Hospital Care Days: The SFC agency may bill Medicaid for up to five consecutive days per hospitalization. The principal caregiver may receive their daily stipend for these days when providing in-person care to the participant in the hospital. A participant must be back in the SFC home for at least 24 hours before a new hospitalization care period can be approved. Hospital care must be documented and coordinated with waiver case management.
Relatives and LRIs: Structured Family Caregiving will be reimbursed when provided by a the parent of a minor child participant or the spouse of a participant (also known as a Legally Responsible Individual), Relative or a Legal Guardian, ONLY when all conditions specified in Appendix C-2-d and Appendix C-2-e of this waiver are met.
Provider Qualifications: The agency must have a current national accreditation or a minimum of three years of experience serving older adults and adults with disabilities, either in Indiana or as a Medicaid-participating provider in another state.
ACTIVITIES NOT ALLOWED:
Household Limit: No more than four participants may be served in a single SFC household.
Service Exclusivity: Participants enrolled in Structured Family Caregiving may not receive duplicative waiver services such as Attendant Care, Homemaker Services, Assisted Living, or Adult Family Care waiver services
Skilled Medical Care: Medical services remain responsibility of healthcare providers and are not covered under the SFC waiver service.
Caregiver Coaches: Parents of minor participants and spouses are not eligible to serve as caregiver coaches.
Last Updated: 8/26/2025
Last Updated: 8/26/2025
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