The Program Being Evaluated

Cash & Counseling offers Medicaid consumers with disabilities choices for obtaining help at home. This program model offers a flexible monthly allowance based on an individualized budget, allowing consumers to directly manage personal assistance services (PAS) and address specific needs. In addition, this program offers counseling and fiscal assistance to help consumers personally manage their allowance and responsibilities.

Cash & Counseling was a national program sponsored by the Robert Wood Johnson Foundation (RWJF), the Office of the Assistant Secretary for Planning and Evaluation in the United States Department of Health and Human Services (ASPE/DHHS), and the Administration on Aging (AoA). A three-state Cash & Counseling Demonstration was implemented in 1998 to compare the Cash & Counseling consumer-directed model with the traditional agency-directed approach to delivering PAS. Following the success of the original demonstration, funders granted an expansion of the Cash & Counseling program, adding eleven states in 2004. Today, the Cash & Counseling model informs discussion and impacts policy surrounding the choices consumers with disabilities have for obtaining help at home.

Evaluation Findings

Mathematica Policy Research (MPR) conducted the preliminary evaluation of the three-state demonstration in Arkansas, New Jersey and Florida. Each state was required to adhere to the basic Cash & Counseling model, but was given the flexibility to implement Cash & Counseling in accordance with their own service delivery systems and political environments.

Findings include:

• Cash & Counseling significantly reduced the unmet needs of Medicaid consumers who require personal assistance services.
• Cash & Counseling improved quality of life for participants and their caregivers.
• Cash & Counseling did not result in misuse of Medicaid funds or abuse of consumers.
• Medicaid personal care costs were somewhat higher under Cash & Counseling, mainly because enrollees received more of the care they were authorized to receive.
• Increased Medicaid personal care costs under Cash & Counseling were partially offset by savings in institutional and other long-term-care costs.
• Cash & Counseling need not cost more than traditional programs if states carefully design and monitor their programs.

The lead evaluator for this program was Randall S. Brown, Ph.D., of Mathematica Policy Research, Inc.

Summary of Methods

MPR conducted a quantitative evaluation, using a randomized design, which analyzed differences in consumer satisfaction, quality of life, the amount and types of obtained PAS, and cost between participants in the states' Cash & Counseling programs and those receiving traditional agency-directed care. The main sources of evaluation data were telephone surveys with demonstration participants and their caregivers, and Medicare and Medicaid enrollment and claims data. MPR also visited state officials and provider agencies to collect information about program implementation.

Knowledge and Impact

This evaluation and its related discussion have contributed to documented changes in federal and state policies. In 2005 the Deficit Reduction Act provided several new options for implementing a Cash & Counseling program. Most notably the program may be implemented within a 1915(i) state plan option for home and community waiver services.

There are a large number of reports detailing extensive analysis and results, which can be found on the Cash & Counseling Web site. A few selected reports are listed below.