CMS has issued a proposed rule that would permit states to administer “self-directed personal assistance services” through their state Medicaid plans. Under this framework, states could provide Medicaid beneficiaries who need help with activities of daily living with a cash allowance to hire, direct, train, or fire their own personal care workers (including family members) rather than work with personnel employed by an agency. Allotments also could be used to purchase items that promote independence, such as a wheelchair ramp. To request state plan change, the state must have an existing personal care services benefit or be operating a home or community-based services waiver program. The state also must adopt quality assurances and other safeguards to protect participant health and welfare. Beneficiary enrollment would be voluntary, and the state also must provide traditional agency-delivered services if the beneficiary wishes to discontinue self-directed care. Comments on the proposal are due February 19.