New Hampshire Self-Directed Care for Developmental Services

Why Self-Direction Matters in New Hampshire

New Hampshire's developmental services system runs through ten regional Area Agencies, each contracted with the Bureau of Developmental Services to coordinate supports for people with intellectual and developmental disabilities. The system works — on paper. In practice, workforce shortages and outdated reimbursement rates (some still tied to 2007 baselines) mean that even when someone is approved for a DD Waiver and funding is allocated, actual services can take months to materialize.

Self-directed care is the workaround families are increasingly turning to. Instead of waiting for an Area Agency to locate and assign a direct support professional, the individual (or their family) manages a budget and hires their own staff directly.

How Self-Directed Budgets Work Under the DD Waiver

Under He-M 503 rules, once someone is found eligible for the DD Waiver and a Level of Care determination is approved, BDS allocates a funding budget based on the person's Supports Intensity Scale (SIS-A) assessment. That budget is typically managed through the Area Agency's service coordination process.

With self-direction, the same budget is placed under the individual's control. The key mechanics:

• Budget authority — the individual or their representative controls how the allocated waiver dollars are spent, within the approved Individual Service Agreement (ISA)
• Employer authority — the individual directly hires, trains, schedules, and if necessary terminates their own support staff
• Fiscal intermediary — a financial management service handles payroll, tax withholding, and Medicaid billing on the individual's behalf, so the family isn't running a small business from scratch

The funding amount doesn't change when you choose self-direction. What changes is who decides how to spend it and who does the hiring.

Practical Advantages Over Agency-Managed Services

The clearest advantage is speed. When an Area Agency can't find staff to fill a residential or day program slot, that waiver authorization sits unused. Under self-direction, a family member, neighbor, or community member can be hired as a direct support professional — someone the individual already knows and trusts.

Other advantages families report:

• Schedule flexibility — services happen when they're needed, not when the agency has an opening
• Continuity — the same person provides support consistently, rather than rotating agency staff
• Tailored supports — the ISA defines goals, but self-direction lets the individual choose activities and settings that actually match their interests
• Rural access — in northern New Hampshire (Region 1, Northern Human Services) and the Upper Valley (Region 2, PathWays), agency-staffed programs may be an hour's drive away; self-directed supports can happen locally

What Self-Direction Doesn't Cover

Self-direction has real limits. It doesn't create additional funding — the SIS-A results still influence the budget. It doesn't eliminate paperwork — someone has to track hours, manage the fiscal intermediary relationship, and document that spending aligns with the ISA. And it doesn't replace the Service Coordinator entirely — a coordinator still helps develop the ISA and conducts periodic reviews.

Families also need to understand employer responsibilities. Even with a fiscal intermediary handling tax withholding, the individual or their representative is the employer of record. That means handling interview processes, background checks required by BDS, and managing the relationship when things aren't working.

Getting Started With Self-Direction

The path runs through the existing Area Agency and Service Coordinator relationship:

1. Confirm waiver eligibility and funding — self-direction requires an active DD Waiver enrollment and an approved ISA budget
2. Request a self-directed option at the next ISA planning meeting — the Service Coordinator is required to present self-direction as an available service delivery model
3. Select a fiscal intermediary — BDS maintains a list of approved financial management services that handle the payroll and billing mechanics
4. Recruit and hire staff — the individual or family identifies candidates, the fiscal intermediary runs required background checks and manages onboarding
5. Track and report — hours and expenditures are documented through the fiscal intermediary; the Service Coordinator reviews spending against the ISA at regular intervals

When Self-Direction Makes the Most Sense

Self-direction works best for families who have a reliable network of potential support workers and the organizational capacity to manage a hiring relationship. It's particularly effective during the transition period between ages 18 and 22, when school services are winding down and Area Agency placements haven't yet materialized — the exact gap where many families feel stuck.

For families navigating this transition, our New Hampshire SSI at 18 & Adult Disability Benefits Guide walks through the full DD Waiver application sequence, He-M 503 timelines, and SIS-A preparation — including how self-directed budgets fit into the broader service plan.

If self-direction isn't the right fit — maybe the paperwork is too much, or there's no local hiring pool — the standard agency-managed model still works. The key is knowing both options exist before you sign the ISA.

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