A CNA can work independently, but only within a narrow lane: federal and state rules require a licensed nurse to supervise clinical nursing tasks, so a certified nursing assistant who goes solo is functioning as a non-medical personal caregiver. You can build a private-pay client base, enroll through a self-directed Medicaid program, or combine the two. What you cannot do is use the CNA title to offer unsupervised clinical care. Crossing that line puts your certification and, in some states, your freedom at risk.
The Supervision Rule That Shapes Everything
State Nurse Practice Acts govern how nursing duties get delegated, and every state requires clinical tasks performed by unlicensed assistive personnel, a category that includes CNAs, to happen under the general supervision of a licensed nurse.1eCFR. 42 CFR 483.152 – Requirements for Approval of a Nurse Aide Training and Competency Evaluation Program The specifics vary, but the underlying principle is the same everywhere. Clinical nursing work flows downward from a licensed nurse through delegation. It does not flow upward from a CNA working alone.
Marketing yourself as a Certified Nursing Assistant to deliver unsupervised clinical services violates these rules. Consequences vary by state and can include permanent loss of your certification, civil fines, and criminal charges for practicing nursing without a license. State boards investigate complaints, and a single substantiated report can end a career.
What You Can Do Alone, and What You Cannot
The line is clinical versus non-clinical care. As an independent personal caregiver, you can help with activities of daily living that don’t require nursing judgment or medical training.
On the allowed side:
- Personal hygiene, including bathing, grooming, dressing, and toileting.
- Mobility support, including transfers between a bed and wheelchair, walking assistance, and repositioning.
- Household tasks such as meal preparation, light cleaning, laundry, and organizing living spaces.
- Companionship, errands, and driving clients to appointments.
- Medication reminders, meaning cueing a client to take medications they manage themselves.
Off-limits without nursing supervision:
- Medication administration beyond verbal reminders, including measuring doses, crushing pills, injecting, or managing IV lines.
- Wound care, including sterile dressing changes, debriding, or managing drainage devices.
- Taking vital signs as part of a treatment plan.
- Catheter and ostomy care, including insertion, irrigation, or anything requiring sterile technique.
The Medication Reminder Gray Area
Medication is where most independent caregivers get into trouble. The field distinguishes administration, a multi-step clinical process requiring licensed-nurse oversight, from reminders, which simply mean telling a client it’s time to take a pill they can handle themselves. Cueing someone or handing them a pre-filled organizer that a pharmacist or family member prepared is routine caregiving. Opening a prescription bottle and placing tablets in a client’s hand starts crossing the line, and the exact boundary depends on your state’s delegation rules. Check with your state board of nursing before offering any medication-related help.
How Independent CNAs Actually Get Paid
There are two realistic paths: private-pay clients who hire you directly, and self-directed Medicaid programs that let recipients hire their own caregivers.
Self-Directed Medicaid
Medicaid’s self-directed services programs give recipients the authority to recruit, hire, train, and supervise their own caregivers rather than going through a home health agency. A Financial Management Service handles the employer-side paperwork, including payroll, tax withholding, unemployment insurance, and workers’ compensation, which takes the administrative burden off the client while giving you funded work.2Medicaid.gov. Self-Directed Services
Enrollment as an independent Medicaid provider requires a background check, verification of your license or certification, and clearance against federal exclusion databases.3eCFR. 42 CFR Part 455 Subpart E – Provider Screening and Enrollment Some states require you to register through a health department portal and upload documentation including your Social Security card, certification, and background check results. Processing often runs two to six weeks. If approved, you get a provider identification number and can begin accepting referrals. Program structure varies, so check your state Medicaid agency’s website for the specifics.
Private-Pay Clients and the Classification Trap
Calling yourself an independent contractor doesn’t make you one in the eyes of the IRS. If a family hires you to come to their home on a set schedule, tells you which tasks to perform, and provides the supplies, you are almost certainly a household employee rather than a contractor, regardless of what a contract says.
The IRS looks at three categories when classifying workers: behavioral control (does the client direct when and how you work?), financial control (do they set your pay rate and provide equipment?), and the nature of the relationship (is it ongoing rather than project-based?). Most private-duty arrangements check every box for employment.4Internal Revenue Service. Independent Contractor (Self-Employed) or Employee?
Classification determines who pays what taxes. When a family pays a household employee $3,000 or more in cash wages during 2026, that family becomes a household employer and must withhold and pay Social Security and Medicare taxes totaling 15.3% of wages, split evenly between employer and worker. The family must also pay federal unemployment tax if total household wages reach $1,000 in any calendar quarter.5Internal Revenue Service. Publication 926 (2026), Household Employer’s Tax Guide Getting this wrong hurts both sides. The family faces back taxes, penalties, and interest if audited; you lose credit toward Social Security benefits and face your own tax problems.
Genuine independent contracting means you set your own hours, serve multiple clients, supply your own equipment, and control how the work gets done. If that describes you, the tax picture shifts to self-employment.
Setting Up the Business Side
Structure and Tax ID
A sole proprietorship is the simplest structure and requires no formal state filing in most places. You can use your Social Security number for tax purposes unless you form an LLC or hire employees, in which case you need an Employer Identification Number from the IRS.6Internal Revenue Service. Employer Identification Number Many caregivers get an EIN anyway to avoid putting their Social Security number on invoices. Most local jurisdictions also require a general business license through the county clerk’s office, with fees commonly between $50 and $150.
Insurance
Two types of coverage matter. General liability insurance protects you if a client is injured while you’re providing care, such as during a transfer. Professional liability coverage, sometimes called errors and omissions, protects against claims that your services caused harm through a mistake or oversight. Carriers typically bundle these for home care providers, with coverage starting at $1,000,000 per occurrence. Annual premiums for independent caregivers tend to run around $100 to $200 depending on state and limits.
Background Check
Whether you register with a state program or work privately, a clean background check is effectively mandatory. State registries require fingerprint-based criminal history checks as a condition of enrollment.3eCFR. 42 CFR Part 455 Subpart E – Provider Screening and Enrollment Private families expect the same. Fingerprinting through approved vendors typically costs $40 to $80 and can take several weeks to process.
Written Care Agreement
A written service agreement protects both sides and is practically essential if Medicaid funds are involved. Without one, payments to a caregiver can be treated as gifts rather than compensation, which can jeopardize a client’s Medicaid eligibility. At minimum, cover:
- Names of both parties (caregiver and client or legal representative).
- Specific services you will and will not provide.
- Schedule, including days, hours, and any built-in flexibility.
- Hourly rate, payment method, and pay schedule.
- Start date and duration.
- Termination clause with reasonable notice on either side.
- Dated signatures from both parties.
Set your rate based on what agencies in your area charge for comparable non-medical care. Pricing far above or below market raises red flags with Medicaid and the IRS. Keep a daily log of tasks and hours; it is your best defense if the arrangement is ever questioned.
Taxes When You Are Self-Employed
If you qualify as self-employed rather than a household employee, you owe self-employment tax on your net earnings. The combined rate is 15.3%, covering both halves of Social Security (12.4%) and Medicare (2.9%).7Internal Revenue Service. Self-Employment Tax (Social Security and Medicare Taxes) For 2026, the Social Security portion applies to the first $184,500 in net earnings; the Medicare portion has no cap.8Social Security Administration. Social Security Update 2026
Because no employer withholds from your pay, you are responsible for quarterly estimated tax payments. For 2026, those are due April 15, June 15, September 15, and January 15, 2027. You generally need to make these payments if you expect to owe at least $1,000 after withholding and credits.9Internal Revenue Service. 2026 Form 1040-ES Estimated Tax for Individuals Missing a quarterly payment triggers an underpayment penalty even if you pay the full amount by April of the following year.
Deductions Worth Tracking
Ordinary business expenses lower the income subject to self-employment tax. Common deductions include:
- Mileage between clients’ homes or for supply pickups, at 72.5 cents per mile for 2026. Keep a contemporaneous log with dates, destinations, and trip purposes.10Internal Revenue Service. IRS Sets 2026 Business Standard Mileage Rate at 72.5 Cents Per Mile
- Supplies and equipment used exclusively for work, such as gloves, uniforms, and blood pressure cuffs.
- Health insurance premiums, deductible at 100% for self-employed individuals who aren’t eligible for coverage through a spouse’s employer.
- Continuing education, certification renewal fees, and related travel.
- The business-use percentage of your cell phone plan.
You can also deduct half of your self-employment tax when calculating adjusted gross income. Keep receipts and bank statements for at least three years, the standard IRS audit window.
A Note on Client Privacy
HIPAA’s Privacy and Security Rules apply to covered entities, defined as health care providers who transmit information electronically in connection with standard transactions like insurance billing.11U.S. Department of Health and Human Services. Covered Entities and Business Associates A private-pay caregiver who doesn’t submit electronic claims likely falls outside HIPAA’s legal reach, though treating client information as confidential is still an ethical and practical necessity. If you later enroll as a Medicaid provider and begin submitting electronic claims, HIPAA’s full requirements apply, including written security policies, breach notification procedures, and safeguards for electronic protected health information.12Centers for Medicare & Medicaid Services. HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules
Keeping Your Certification Active
Working independently doesn’t exempt you from maintaining your CNA certification. Every state requires periodic renewal, and most tie it to proof that you have performed nursing-related activities for compensation within the preceding two years. If you work exclusively as a private companion without documenting qualifying care tasks, you may need to retake the competency evaluation before recertifying. Continuing education requirements vary widely by state; some mandate a set number of hours, others have no formal requirement. Contact your state board of nursing well before your expiration date to confirm what’s needed, and keep documentation of qualifying work as you go.