Receive Payment as a Caregiver: Cash and Counseling Programs

How Cash and Counseling Works	Cash and Counseling Eligibility	Cash and Counseling Programs
Overview of Cash and Counseling

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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.  Today 47 states offer some form of consumer direction in their assistance programs for the elderly..

 

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 some states even their spouses.  Most programs have a provision that allows surrogate decision makers to help the senior 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.

Skilled Nursing, Assisted Living and Individuals in Group Homes.
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.
 

-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.  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 of the participating states has their own requirements for their Cash and Counseling programs.  However, generally speaking if an individual is eligible for Medicaid, then they are eligible for a Cash and Counseling program.  Medicaid eligibility is determined at the state level.  Follows are Medicaid’s generalized eligibility requirements.  

It is worth noting that there are now some non-Medicaid programs with less rigid requirements that operate on the Cash and Counseling model as well.  These can be found by exploring the program links further down this page.
 

To be eligible for Medicaid and therefore a Cash and Counseling program, an individual must either be over the age of 65 or have a disability.

 

Medicaid disability requirements differ by state, but generally speaking, if financially qualified, any person that requires skilled nursing or is mentally impaired with Alzheimer's / dementia will 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.

 

Medicaid / Cash and Counseling Income Limits
The income thresholds for Medicaid eligibility are determined at the state level but all of them use one of the two following  methods.  Again it worth noting there are also non-Medicaid Cash and Counseling programs. 

• Income Cap States use the federal income cap which is 3 x SSI payment standard. For 2011, this limit is approximately $2,022 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 States looks at the applicant’s income and the cost of care. If an applicant cannot afford the cost of care, he or she will qualify.

Income Cap States		Non-Income Cap States
Alabama Alaska Arizona Arkansas Colorado Delaware Florida Georgia Idaho Iowa Kentucky	Louisiana Mississippi Nevada New Jersey New Mexico Oklahoma Oregon South Carolina South Dakota Tennessee Texas Wyoming	California Connecticut Hawaii Illinois Indiana Kansas Maine Maryland Massachusetts Michigan Minnesota Missouri Montana	Nebraska New Hampshire New York North Carolina North Dakota Ohio Pennsylvania Rhode Island Utah Vermont Virginia Washington West Virginia Wisconsin

 

For couples, where one spouse requires care in a facility and the other is healthy enough to remain at home, the spouse living at home is known as the “community spouse” and is entitled to a certain amount of income. The 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.

Medicaid / Cash and Counseling Asset Limits
Medicaid applicants' resources are a major factor in eligibility.  Resources might also be referred to as their "assets" or "countable assets."  State asset limits range from $1,000 to $8,000, 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. For example, the applicant must live in their home or intend on returning to their home.  Also the home must be in the same state in which the applicant is applying for Medicaid.  Finally, his or her equity in the home must be valued at less than $500,000.  

For couples, the "community spouse" is entitled to a certain amount of resources, half of the couple's resources up to approximately $110,000 in 2011. (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.

 

Medicaid is available to both Veteran and non-Veterans.  There is also a Cash and Counseling program specifically for Veterans.

 

As of 2011, 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.
 

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas

Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York

North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

 What are the Benefits of Cash and Counseling Programs?

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.

 

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.

 

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.

 

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.

 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

Depending on one’s state of residence and the specific Cash and Counseling program for which they are interested, the enrollment process varies.  Choose any of the links below to read more about a specific Cash and Counseling program or program that allows for Consumer Direction.

Cash and Counseling Programs for Veterans
Cash and Counseling for Veterans or Veterans Directed HCBS
 
Non-Medicaid Programs with Consumer Direction
Hawaii Chore Services Program
Kentucky Hart-Supported Living Program
Kentucky Personal Care Attendant Program
Maine Home Based Care
Minnesota Alternative Care Program
New Hampshire Transitions in Caregiving
Oregon Project Independence
Texas: Community Attendant Services Program
Utah The Alternatives Program
Wisconsin Family Care and Partnership Programs
West Virginia Ron Yost Personal Assistance Services
West Virginia Lighthouse Program

Medicaid Programs with Consumer Direction
Alabama Elderly and Disabled Waiver
Alabama Personal Choices Program
Alabama SAIL Waiver
Alaska Personal Care Assistance Program
Arizona Self Directed Attendant Care
Arkansas Independent Choices Program
California In-Home Supportive Services
Colorado Consumer Directed Attendant Support Services
Colorado HCBS Waiver the Elderly, Blind, and Disabled
Connecticut Personal Care Assistance Program
Delaware Elderly and Disabled Waiver
Florida CDC+ Waiver
Idaho Aged and Disabilities Waiver
Idaho Personal Care Services Program
Indiana Aged and Disabled Waiver  
Iowa Elderly Waiver
Kansas HCBS for the Frail Elderly
Kentucky HCB Waiver for Aged and Disabled
Louisiana Community Choices Waiver
Maine’s Older Adults and Adults with Disabilities Waiver
MaineCare Consumer Directed Attendant Services
Massachusetts Personal Care Attendant Program
Massachusetts Caregiver Homes
Michigan Choice Waiver Program
Michigan Home Help Program
Minnesota Consumer Support Grant
Minnesota Elderly Waiver
Minnesota Personal Care Assistance Program
Mississippi Elderly and Disabled Waiver
Missouri Aged and Disabled Waiver
Montana HCBS Waiver
Montana Self-Directed Personal Assistance Services
Nebraska Aged and Disabled Waiver
Nevada COPE and HCBW
New Hampshire Choices For Independence
New Jersey Global Options
New Jersey Personal Preference Program
New Mexico Mi Via Program
North Carolina CAP-DA Waiver
New York Consumer-Directed Personal Assistance Program
Ohio CHOICES Waiver
Oklahoma Advantage
Oklahoma Personal Care Program
Oregon Client-Employed Provider Program
Oregon Independent Choices Program
Oregon Spousal Pay Program
Pennsylvania Aging Waiver
Pennsylvania Services My Way
Rhode Island Personal Choices
South Carolina Choice and Attendant Care
Tennessee CHOICES in Long-Term Care
Texas Community Based Alternatives
Texas Primary Home Care
Vermont Attendant Services Program
Vermont Choices For Care (CFC)
Virginia Elderly or Disabled Waiver
Washington COPES
Washington Medicaid Personal Care (MPC) Program
Washington Medically Needy In-Home Waiver
Washington New Freedom Program
West Virginia Aged and Disabled Waiver
Wisconsin IRIS Program
Wyoming HCBS Waiver

Other Web Resources
The National Resource Center for Participant-Directed Services at Boston College also maintains a database of programs with consumer direction.  Use their Program Locator here.