Cash & Counseling 101

Cash & Counseling: Program Overview Funders

The Robert Wood Johnson Foundation US DHHS/ASPE Administration on Aging

Waiver and Program Oversight Centers for Medicare and Medicaid Services

National Program Office Boston College Graduate School of Social Work

Evaluator Mathematica Policy Research, Inc.

Original Cash & Counseling Demonstration OverviewDemonstration States

Arkansas, Florida, New Jersey

Study Populations Adults with disabilities (Ages 18-64) Elders (Ages 65+) Florida only: Children with developmental disabilities

Feeder Programs Arkansas and New Jersey: Medicaid personal care option programs Florida: Medicaid 1915c Home and Community-Based long-term

care waiver programs

Basic Model for Cash & Counseling

Step 1: Consumers receive traditional assessment and care plan

Step 2: A dollar value is assigned to that care plan

Step 3: Consumers receive enough information to make unbiased personal choice between managing individualized budget or receiving traditional agency-delivered services

Basic Model for Cash & Counseling

Step 4: Consumer and counselor develop spending plan to meet consumer’s personal assistance needs

Step 5: Cash allowance group provided with financial management and counseling services (supports brokerage)

Original and Expansion Cash & Counseling States

Receiving Monthly Allowance at 9 Months (Treatment Group Members Living in Community)

77

5461

72

39

6170

0

20

40

60

80

100

Non-Elderly Adults

Percent

AR FL NJ AR FL NJ FL

Elderly Adults Children

Receiving Paid Assistance at 9 Months

95

76

92 94 94 94

80

68 64

79 79

65

91

82

0

20

40

60

80

100

Non-Elderly Adults

*, ** Significantly different from control group at .05, .01 level, respectively.

Percent

T C AR


T C FL

T C NJ

T C AR

T C FL

T C NJ

T C FL

**** ** **

****

Very Satisfied with Overall Care Arrangements

68

505657

68

52

71

27

54

42

35 37

4748

0

10

20

30

40

50

60

70

80 Non-Elderly Adults


Percent

T C AR


T C FL

T C NJ

T C AR

T C FL

T C NJ

T C FL

**

**** **

****

Had an Unmet Need for Help with

Personal Care

41

34

55

37

47

58

4543

3633

4446

2726

0

10

20

30

40

50

60Non-Elderly Adults


Percent

T C AR


T C FL

T C NJ

T C AR

T C FL

T C NJ

T C FL

**

**

**

*

*

Contractures Developed or Worsened

26

14

2022

27

13

9

2018

16

9

2528

25

0

10

20

30



Percent

T C AR


T C FL

T C NJ

T C AR

T C FL

T C NJ

T C FL

**

**

Very Satisfied with Way Spending Life These Days

43

64

38

56

36

4752

29

23

50

21

37

2825

0

20

40

60



Percent

T C AR


T C FL

T C NJ

T C AR

T C FL

T C NJ

T C FL

****

**

****

**

*

Informal CaregiversVery Satisfied with Overall Care

*,**,*** Significantly different from control group at .10 (*), .05 (**), or .01 (***) level.

4852

4243

30 32

22

0

20

40

60

PercentAdults Children

T T T TC C C C

AR FL NJ FL

***

******

***

Informal Caregivers Experienced Less Emotional Strain

27

36

4239

3439

49

42

0

10

20

30

40

50

60Percent Adults Children


T T T TC C C C

AR FL NJ FL

***

**

Informal Caregivers Experienced Less Physical

Strain

2328

32 3432

3942 42

0

10

20

30

40

50

60Percent

Adults Children


T T T TC C C C

AR FL NJ FL

***

****** ***

Informal Caregivers Experienced Less Financial

Strain

22

30 30

44

3639 39

56

0

10

20

30

40

50

60Percent

Adults Children


T T T TC C C C

AR FL NJ FL

***

*** ***

***

Working ConditionsDirectly Hired Agency

Hourly Wage

AR

FL and NJ

$6.00

$10.00

$6.30

$9.00

Receives Fringe Benefits 2 to 5% 17 to 24%

Very Satisfied with Wages and Benefits

41 to 50% 19 to 23%

Very Satisfied Overall 79 to 85% 69 to 83%

Training and Preparedness of Directly Hired Workers

Half trained in personal care or routine health care

On the other hand—

Felt well-informed about care recipient’s condition (~90%)

Felt fully prepared for job (>90%)

Injuries and physical strain similar to agency workers providing equal hours of care

Effects on Medicaid PCS/HCBS Expenditures—Year 1

Significantly Higher for Treatment Group in Each State

In AR and NJ, Mainly Because Control Group Received Substantially Less Care Than Authorized

In FL, Mainly Because Children and Adults With Developmental Disabilities Got Larger Benefit Increases After Assigned to Treatment Group

Effects on Medicaid PCS/HCBS Expenditures—Year 1

AR FL NJ

Adults

Nonelderly

+124%

($3,005)**

+20%

($3,696)**

+21%

($1,946)**

Elderly +88%

($2,021)**

+4%

($433)

+12%

($1,241)**

Children -- +26%

($3,319)**

--

**Significantly different from zero at .01 level.

Effects on non-PCS Medicaid Expenditures

Other Medicaid Costs Moderately Lower For Treatment Group in Each Age Group in All Three States

The Best Example: In AR , Compared to Control Group, Treatment Group Had

40% Fewer Admissions to Nursing Facilities in Second Year

Effects on non-PCS Medicaid Expenditures—Year 1

AR FL NJ

Adults

Nonelderly

-17%

(-$1,743)*

- 6%

(-$369)

-7%

(-$1,132)

Elderly -4%

(-$320)

-5%

(-$296)

-5%

(-$413)

Children -- -15%

(-$2,439)*

--

*Significantly different from zero at .05 level.

Effect on Total Medicaid Costs

In AR, No Significant Difference by End of Year 2 Reductions in NF and other Waiver Costs Off-Set Increase in

Personal Care Costs

In NJ and FL, Costs Up 8-12%, But States Learned How to Control Costs

Higher Costs in AR and NJ Due to Failure of Traditional System

Effect on Total Medicaid Costs—Year 1 vs. Year 2

AR FL NJ

All Adults

Year 1

Year 2

+14%**

+5%

+9%

+12%**

+4%

+12%**

Children

Year 1

Year 2

-- +3%

+8%

--

**Significantly different from zero at .01 level.

Policy Implications Can increase access to care

Greatly improves quality of life (all ages)

Caregivers also benefit greatly

States may be concerned about costs

But have learned how to control them

Cash & Counseling 101

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