This week, the National Cash & Counseling program launched a public relations campaign aimed at state policymakers to emphasize that under the Deficit Reduction Act (DRA), all states can more easily introduce a Cash & Counseling option in their Medicaid programs. Effective January 1, 2007, Section 6087 of the DRA provides that state Medicaid programs can offer the Cash & Counseling model of self-directed personal assistance services to frail elders and adults and children with disabilities without first obtaining a federal waiver. Instead, the option can be made available through a state plan amendment. According to Kevin J. Mahoney, PhD, director of the Cash & Counseling National Program Office at the Boston College Graduate School of Social Work, “The federal waiver process is long, cumbersome, and difficult for states, and our expectation is that Section 6087 will address many of the issues that currently hinder states that want to offer self-direction to consumers who prefer it.”
The self-directed personal care model gives frail elderly people and adults and children with disabilities who are eligible for Medicaid personal care services the option to manage a flexible budget and decide for themselves what mix of goods and services will best meet their personal care needs—essentially help at home with daily activities like bathing, dressing, grooming, and meal preparation. Under the new DRA provision, participants may use their budget to hire their own personal care aides, including family members and friends, as well as purchase items or make home modifications that help them live independently.
Cash & Counseling began as a demonstration in Arkansas, Florida, and New Jersey. Currently, 12 more states are implementing self-directed personal care programs: Alabama, Illinois, Iowa, Kentucky, Michigan, Minnesota, New Mexico, Pennsylvania, Rhode Island, Vermont, Washington, and West Virginia.
A hallmark of self-directed personal care is the individual budget that allows beneficiaries to obtain and manage their services. A recently released report of the Kaiser Foundation, Beyond Cash and Counseling: The Second Generation of Individual Budget-based Community Long Term Care Programs for the Elderly, reviews 10 individual budget model programs that serve older persons and identifies four elements of program design that are important to success as follows:
- Level and adequacy of benefits. How the initial amount is set and mechanisms to adjust for changing needs over time impacts adequacy. Average individual budgets vary dramatically across states from about $400 in Arkansas to $4,000 in Colorado.
- Participant choice. Not all long term care recipients prefer consumer direction nor is it always appropriate. Beneficiaries must be willing to assume some of the management and fiscal responsibilities traditionally borne by agencies.
- Participant support systems. State programs are required to include systems to support recipients to develop and manage their budgets and obtain services, but the level of support currently varies across states. Both the level of support and its funding mechanism can affect whether participants, especially participants with greater needs, are successful.
- Quality of care monitoring. Self-directed care assumes that there will be some risk in exchange for greater self-determination, but states retain ultimate responsibility for assuring adequate care. Counselors are the first-line quality monitors and typically visit recipients quarterly or semi-annually to monitor for service problems, abuse, neglect or changes in the beneficiary’s condition.
The Kaiser Report identifies the following key implications:
- Careful attention to the interdependence of budget adequacy, quality of care, and choices and management supports available to participants is warranted.
- Longer experience, larger enrollments, and evaluation evidence are needed to reveal how different program designs perform in attracting older participants and achieving better outcomes for them, as well as the implications for state spending.
- Participation may increase with newer designs that allow older beneficiaries to choose whether to manage a budget for all home and community-based services or only some services.
The complete report is available on the Kaiser Foundation Web site at 
http://www.kff.org/medicaid/upload/7579.pdf. For a copy of the Cash & Counseling press release, go to 
http://www.cashandcounseling.org/news/20070129-103206/PressRelease.doc and for general information on Cash & Counseling, go to http://www.cashandcounseling.org/index_html.