5 Key Questions on The Family Certified Nursing Assistant (CNA) Model

On November 6, 2025, Manatt Health hosted a webinar titled “The Family CNA Model: How Medicaid Can Help Improve Outcomes for Children with Medical Complexity,” which provided an overview of the Family CNA model and discussed opportunities to expand the model through State Medicaid Programs. The Family CNA model trains and reimburses family members—including parents, guardians, siblings, aunts, uncles, and grandparents—to provide certain types of home care for children with medical complexity that would otherwise be provided by a registered nurse (RN), a licensed practical nurse (LPN), or a non-family CNA.

Webinar participants raised several questions about the model, which we answer in today’s Newsletter. Additional information on opportunities to expand the model can be found in a published by Manatt Health in partnership with Team Select Home Care, Lucile Packard Foundation for Children’s Health, Family Voices and Health Leads.

1. How can state Medicaid Programs implement and benefit from the Family Certified Nursing Assistant (CNA) model?

Most states that have implemented a Family CNA model, or are in the process of doing so, have done so under Medicaid’s mandatory home health or optional private duty nursing (PDN) state plan benefit. A handful of states, including North Carolina, have implemented a Family CNA model through a 1915(c) home- and community-based services waiver. States can also explore implementing the Family CNA model through a Medicaid 1115 Demonstration, where there is some precedent for paying family caregivers. Given that every state Medicaid program is different, each state should evaluate its existing authorities, program structures and benefits for children with medical complexity and aim to implement the Family CNA model in a way that maximizes access and quality while balancing cost considerations. The Family CNA model creates an opportunity for potential state cost savings, as nearly half of all Medicaid spending for children with medical complexity goes towards hospital care. The Oklahoma Health Care Authority, for example, found that would result in over each year, according to a by the state legislature.

Currently, states have implemented the Family CNA model only for families of children with medical complexity, but the model could also benefit and be adapted for families of older adults, adults with disabilities (including adult children of family CNAs) and children with medical complexity enrolled in employer-sponsored or other non-Medicaid coverage.

Nearly half of all Medicaid spending for children with medical complexity goes towards hospital care. Providing care in the home is the right thing for a child’s care and quality of life and one of the greatest opportunities for cost savings for states and families. For example, the Oklahoma Health Care Authority found that implementing a family CNA program would result in over $3 million in savings each year, according to a by the state legislature.

2. What could the Centers for Medicare and Medicaid Services (CMS) and other federal agencies do to support expansion of the model?

Opportunities for federal action to expand the Family CNA model include:

• CMS can establish an intra-agency workgroup (e.g., with the Administration for Community Living), to develop a standardized definition, training requirements and a set of billing codes for the family CNA role and services, in addition to appropriating safety and quality standards.
• CMS can adopt the recommendation in the National Strategy to Support Family Caregivers to encourage state Medicaid programs and other insurance programs to expand community-based long-term care options that allow for the hiring of family caregivers, including explicitly through the Family CNA model.
• Congress can fulfill the unrealized promises of the 21st Century Cures Act to invest in family caregiver trainings.

The Family CNA model could also benefit families of older adults, adults with disabilities (including adult children of family CNAs) and children with medical complexity enrolled in employer-sponsored or other non-Medicaid coverage. This would require benefit design, training and other program requirements tailored to these populations.

3. How is the Family CNA model different from personal care attendant models where family caregivers can be paid to deliver services?

Some key differences between the Family CNA model and some personal care attendant models (which vary by state) that pay family caregivers include:

• A family CNA is trained and paid to provide low-acuity medical tasks and support a child with activities of daily living. These tasks can include medication administration, gastronomy tube care or catheter care.
• A family CNA is employed and paid by a home health agency, which is responsible for the clinical oversight of the family CNA and facilitation of billing and payment processes for the services provided.
• Family CNA services are considered medical care and are medically ordered by a physician under a PDN or Home Health benefit. Personal care is considered non-medical care that is necessary to support activities of daily living and does not require a medical order.

States can implement both the Family CNA model and other paid family caregiving models (e.g., self-directed personal care attendant models) in their Medicaid programs and should consider a variety of options for families to choose from.

4. How is Family CNA training different from other CNA trainings (e.g., for older adults)?

Family CNA training is, at minimum, equivalent to the training that other CNAs receive and can include training specifically on the needs of children with medical complexity and on more advanced skills depending on state requirements, such as feeding tube care and medication administration. Family CNA training is often offered for free by home health agencies, and training varies by state based on each state’s specific training requirements. 

5. What barriers to access exist for people who want to become a Family CNA?

Awareness of the model and accessible trainings are two barriers that states and home health agencies can address in working to expand utilization of the Family CNA model. States can conduct outreach and develop informational materials to build awareness of the model. Outreach should aim to address potential language and cultural barriers. States can consider leveraging partnerships with community-based organizations and existing family CNAs to reach communities. In addition, states can work with home health agencies and hospitals to deliver training that is free to families and available in multiple languages and multiple modalities (e.g., remote/online training, stipends for family members to travel and take time off from work to attend training). Hospitals can play an important role in supporting training for families whose children are being discharged to home health services.

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