Most U.S. states offer at least one pathway to pay spouses who serve as caregivers, primarily through Medicaid waiver programs. A 2024 survey found that 40 states allow payments to legally responsible relatives (including spouses) through Medicaid waiver programs. Beyond Medicaid, the VA’s Program of Comprehensive Assistance for Family Caregivers pays qualifying spouses of eligible veterans a monthly stipend. The specifics vary widely by state, program, and your spouse’s medical situation.
Medicaid Waiver Programs: The Most Common Route
Medicaid is the largest funding source for paid spouse caregiving in the United States. Under home and community-based services (HCBS) waiver programs, states can authorize payments to family members, including spouses, who provide care that would otherwise require a nursing home or facility. Forty states currently allow these payments through waiver programs, though the rules differ in important ways from state to state.
The key concept is “extraordinary care.” Federal rules let states pay legally responsible relatives (spouses, parents of minor children) only when the care being provided goes beyond what a family member would ordinarily do. In practice, this means your spouse needs a level of assistance with daily activities, medical tasks, or supervision that is significant enough to justify paying someone to do it. If your spouse qualifies for Medicaid and has care needs that would otherwise lead to placement in a facility, you may be eligible.
Only six states allow spouse caregiver payments through their standard Medicaid state plan rather than through a waiver. The distinction matters because state plan services are an entitlement (anyone who qualifies gets them), while waiver programs often have waitlists and limited enrollment slots. Three states did not respond to the 2024 KFF survey at all: Florida, Indiana, and Utah.
How Much Spouse Caregivers Get Paid
Pay rates vary significantly depending on the state, the program, and the level of care your spouse requires. To give a concrete example, North Carolina pays family caregivers between $10 and $15 per hour through its Medicaid Community Alternatives Program, with monthly budgets typically ranging from $1,500 to $3,000. State-funded programs in North Carolina pay slightly less, between $9 and $14 per hour.
These figures are broadly representative of what many states offer, though rates in higher cost-of-living states tend to be somewhat higher. The monthly amount you actually receive depends on how many hours of care are authorized in your spouse’s plan of care, not on what you’d charge as an outside professional. A care coordinator or case manager assesses your spouse’s needs and sets a budget, and your hourly rate and authorized hours come from that budget.
Self-Directed Care Programs
Some states offer self-directed options where the person receiving care (or their representative) manages a budget and hires their own caregivers, including a spouse. California’s In-Home Supportive Services (IHSS) program is one of the best known. These self-directed models give families more control over scheduling, hours, and which tasks get prioritized, but they also come with employer responsibilities like tracking hours and filing payroll paperwork.
VA Caregiver Payments for Spouses of Veterans
If your spouse is a veteran, the Program of Comprehensive Assistance for Family Caregivers (PCAFC) offers a monthly stipend to spouses who provide ongoing personal care. The stipend amount is tied to the level of care needed and is based on the pay rate for home health aides in your area.
To qualify, the veteran must have a VA disability rating of 70% or higher (individual or combined), need at least six continuous months of in-person personal care, be enrolled in VA health care, and have been discharged from military service. The caregiver must be at least 18 years old and either be a family member or live full time with the veteran.
The VA program also provides health insurance for the caregiver (if they don’t already have it), mental health counseling, respite care, and training. Stipend payments are made through direct deposit on a monthly basis. To apply, you can submit VA Form 10-10CG online or call the Caregiver Support Line at 855-260-3274 for help with the application. A Caregiver Support Team Coordinator at your nearest VA health facility can also walk you through the process.
Veterans who don’t meet the PCAFC threshold may still qualify for the Veteran Directed Home and Community-Based Services program, which functions more like Medicaid’s self-directed model. In North Carolina, for instance, this program pays family caregivers $12 to $16 per hour.
Tax Treatment of Caregiver Payments
One detail many spouse caregivers miss: payments you receive through Medicaid waiver programs may be completely excluded from your federal taxable income. The IRS treats these as “difficulty of care” payments under Notice 2014-7, which means you don’t owe federal income tax on them. The exclusion applies when you live in the same home as the person you’re caring for, which is almost always the case for spouses.
To claim the exclusion, you sign a statement under penalty of perjury confirming that you’re an individual care provider receiving Medicaid waiver payments for care you provide to someone who lives in your home. More than one care provider living in the same home can claim the exclusion. This can make a meaningful difference in your household finances, since the full payment stays in your pocket rather than being reduced by taxes. VA caregiver stipends are also generally not taxable.
How to Apply for Spouse Caregiver Payments
The entry point depends on which program you’re pursuing. For Medicaid-based programs, start by contacting your state’s Medicaid office or your local Aging and Disability Resource Center. You can find your nearest center by calling 211 or searching online for your state’s ADRC. A case manager will assess your spouse’s care needs, determine eligibility, and explain which waiver programs are available in your area. Be prepared for the process to take several weeks, and ask specifically about waitlists, since many HCBS waiver programs have them.
For VA programs, the most direct route is calling the Caregiver Support Line at 855-260-3274 or visiting your nearest VA health facility to connect with a Caregiver Support Team Coordinator. You can also get help from a Veterans Service Organization (VSO), which provides free assistance with applications. The VA application (Form 10-10CG) can be completed online.
Regardless of the program, your spouse will need to meet income and medical eligibility requirements. Medicaid programs are income-based, so your household income and assets will be evaluated. VA programs focus on disability rating and care needs rather than income. In either case, a formal assessment of your spouse’s daily care needs is the first step toward getting authorized hours and a payment rate.