Receive Payment as a Caregiver: Cash and Counseling Programs
Overview of Cash and Counseling
Program Background and Recent Changes:
The Cash & Counseling Program began as a pilot Medicaid program in 15 states with the objective of increasing the participants’ control over their care services. Traditionally, Medicaid would contract with home care agencies to provide personal assistance services such as help with bathing, dressing, grooming and cooking to eligible seniors. Under Cash & Counseling programs, care recipients were given the flexibility to choose their own home care agencies. Family members could act as a “home care agency”. This meant that relatives, such as the adult children of aging parents, could be hired and paid for the personal assistance they provided. Family members could be paid caregivers.
Since the original pilot program, both the concept of Cash and Counseling and the number of states in which it is available has expanded considerably. In addition, the name "Cash and Counseling" is now also referred to as Consumer Direction, Participant Direction and Self Directed Care. The organization tasked with the administration of the original Cash and Counseling program is now referred to as the National Resource Center for Participant-Directed Services (NRCPDS).
Originally a Medicaid-only program, the concept of consumer direction now applies to some non-Medicaid programs and veterans programs as well. As of January 2013, 43 states offered consumer direction in their Medicaid programs. There are also 12 states that allow for consumer direction in non-Medicaid elderly assistance programs and 33 states which allow for some veterans services to be consumer directed.
How Cash and Counseling Programs Work:
Most individuals introduction to Cash and Counseling programs begins with the question: how can I get paid to be a caregiver? For seniors that are already Medicaid eligible, the process begins with an assessment in the home to determine the senior’s care needs; this includes interviews with caregivers and the senior’s physicians. A determination of how many monthly care hours are required is made. A benefit amount or budget is calculated using the number of care hours and cost of care for that geographic area. This budget can be increased or decreased as the senior’s needs change.
Program participants are considered to be “employers” and they decide how to allocate the budget. They can hire family members as “employees”, including their adult children and in a few states even their spouses. Most programs have a provision that allows surrogate decision makers to help the individual in need of care with the selection of care providers and the management of funds. To avoid conflicts of interest, usually the surrogate decision maker and the individual being paid for caregiving cannot be one in the same.
Some state programs require that financial management companies be used to make sure applicable payroll taxes are filed (remember the senior is considered “an employer”). An exception occurs if payments are less than the limit at which payroll taxes are due.
Originally, the Cash and Counseling program was designed specifically for in-home care. Today some states have expanded their programs to include individuals that reside in small group homes and even some assisted living residences. However, nursing home residents are not eligible to participate in Cash and Counseling programs.
Be Aware That:
-Cash & Counseling was the name given to the grants that originally funded the program.
-Most states have their own names for their Cash and Counseling Programs, typically associated with a specific Medicaid waiver. For example in Arkansas it is called “IndependentChoices”, in Florida “Consumer-Directed Care Plus” and in New Mexico, “Mi Via”.
-There is a similar program referred to as Cash and Counseling for Veterans or Veterans Directed HCBS
Qualifications - What are the Eligibility Guidelines for Cash and Counseling Programs?
Each participating state has its own requirements for their Cash and Counseling programs. Typically, an individual qualifies for Medicaid, then applies for the specific Medicaid waiver that allows for consumer direction. While Medicaid is an entitlement program, Medicaid waivers are not and waiting lists can exist.
It is worth noting that some non-Medicaid programs with less rigid financial requirements operate on the Cash and Counseling model as well. These can be found by exploring the program links further down this page.
While there is not a specific age requirement, most Cash and Counseling programs require the individual to be eligible for a specific Medicaid Waiver and many of those require the individual to be at least 65 years of age or disabled.
Disabilities / Health Requirements
Medicaid disability requirements differ by state, but generally speaking, if financially qualified, persons that require skilled nursing or have a severe mental impairment such as Alzheimer's or dementia qualify. If skilled nursing is not required, then Medicaid links eligibility to the number of ADLs (activities of daily living
) with which an individual requires assistance such as dressing, bathing, cooking etc.
Medicaid does not require individuals to have a specific family status, but the financial requirements change if one is single or married.
Financial Status Requirements
Medicaid / Cash and Counseling Income Limits
The income thresholds for Medicaid eligibility are determined by states. Each state uses one of the two following methods.
- Income Cap States use the federal income cap which is 3 x SSI payment standard. For 2013, this limit is approximately $2,130 a month. If one’s income is below this amount, then one qualifies. If their income exceeds this amount, it is possible they can still qualify, but they will need to work with a legal professional to set up an Income Cap Trust / Miller Trust.
- Non-Income Cap or Spend-Down States looks at the applicant’s income and their cost of care. If an applicant cannot afford their cost of care, he or she will qualify.
|2013 Income Cap States||2013 Spend-Down States|
||15. New Jersey
||15. New Hampshire
||16. New Mexico
||16. New York
||17. North Carolina
||18. North Dakota
||19. South Carolina
||20. South Dakota
||21. Rhode Island
||26. West Virginia
When one spouse requires residential care and the other is healthy enough to remain at home, the spouse living at home is known as the “community spouse”. They are entitled to a certain amount of income. A community spouse's income consists of income solely in his or her name plus half of any income that is in the joint name of both spouses. Couples in this situation might wish to consult with a Medicaid planning professional
to ensure the community spouse has sufficient income on which to live and the spouse requiring care does not compromise their Medicaid eligibility.
Medicaid / Cash and Counseling Asset Limits
Medicaid applicants' resources are a major factor in eligibility. Resources are also referred to as "assets" or "countable assets." State asset limits range from $1,000 to $15,000, but most are around $2,000. There are a considerable number of exceptions made when determining what is counted as an asset. For example, the Medicaid applicant's home can be a "non-countable" asset. Other exempt assets can include:
- Clothing, furniture, and jewelry
- One motor vehicle
- Prepaid funeral plans
- Assets that are considered "inaccessible" for one reason or another
For a home to be considered exempt there can be additional requirements. The applicant must live in their home or intend on returning to it. Also the home must be in the same state in which the applicant is applying for Medicaid. Usually, their equity in the home must be valued at less than $536,000 although in some states, this can be much higher.
For couples, a "community spouse" is entitled to a certain amount of resources, half of the couple's resources up to approximately $115,920 in 2013. (Note: this amount may be lower in some states.) Again, just because one’s assets exceed the limit, this does not automatically disqualify persons for the Medicaid program.
Working with a Professional to be Financially Eligible for Medicaid
As mentioned previously, the financial eligibility rules for Medicaid are very complex. There are approaches and strategies that help seniors gain eligibility. It is recommended that seniors consult with Medicaid experts prior to application. Case Managers from the local Area Agency on Aging office may be able to help as well as Private Geriatric care managers. However, working with a Medicaid Planner ensures the greatest possibility of acceptance while at the same time helping families to preserve as much of their assets as possible.
Veteran Status Requirements
As of 2013, programs based on the Cash and Counseling model or programs that had some element of consumer direction were currently available in the following 48 states. It is worth noting that not all of these programs are Medicaid based; some are designed specifically for Medicaid ineligible individuals and others for Veterans.
What are the Benefits of Cash and Counseling Programs?
Types of Benefit Payout
Benefit distribution from Cash & Counseling programs vary by state and program type. In general, the benefits to a participant are increased control and flexibility with regards to how their care dollars are spent. Participants are granted a budget instead of being provided with care services and they are granted a certain amount of control over how the budget is spent. Some programs provide participants with cash directly and others make use of a financial management company or “fiscal intermediary” that handles payments to care providers on the participant’s behalf.
Restrictions on How Payout Can be Used
Typically when an individual joins a Cash and Counseling program, certain restrictions or limitations are set with regards to how their care budget can be spent. Within those guidelines, participants are free to determine what goods and which service providers they prefer.
Many programs allow participants to hire family members to provide them with personal care. The money can also be used to purchase items related to their activities of daily living; a cleaning service, meal preparation, laundry service and transportation for medical appointments are also acceptable services.
Benefits Amounts & Limits
Cash & Counseling programs' monthly allowances are determined by need and the average cost of care for a particular geographic area. In addition, most states cap the maximum monthly allowance to not exceed what the cost would be if the state were to provide the care services.
In the original Cash and Counseling pilot program, monthly state caps ranged from approximately $500 to $4,000. However, today given the diversity and broad range of Cash and Counseling model programs, it is impossible to say what the maximum limits are.
Time to Receive Benefits
If the care recipient is currently receiving Medicaid benefits, families should expect 2-4 months of processing time prior to receiving payments for caregiving. Should the care recipient not be receiving Medicaid benefits, one should estimate an additional 45-90 days for Medicaid enrollment to process. Again, it is worth noting that some Medicaid waivers have waiting lists. Time spent on a waiting list is not included in these averages.
Families in the situation of waiting for Medicaid eligibility or waiting for a Medicaid waiver slot to become available may have to cover the cost of caring for a loved one during this time. Bridge loans or short term loans are available to help in this situation. Click here for more information
Costs to Participate in a Cash and Counseling Program
These programs are designed for lower income individuals and therefore there are no caregiver or care recipient costs to enroll. Enrollment in Medicaid does not require monthly payments. There may be co-pay amounts but these are very minor.
How to Apply for Cash and Counseling Programs
Page Reviewed / Updated - Jun. 2013