Page Reviewed / Updated - Apr. 2015
Cash & Counseling Programs are financial and care assistance programs, usually but not always from Medicaid, which provide the beneficiary with cash assistance and with the flexibility to "consumer direct" or self direct the spending of the cash on the care providers of their choosing.
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, “Self-Directed Community Benefit”.
The Cash & Counseling Program began as a pilot Medicaid program in 15 states with the objective of increasing participants’ control over their care services and providers. Traditionally, Medicaid would contract with home care agencies to provide personal assistance services such as help with bathing, dressing, grooming and cooking. Under Cash & Counseling, 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 become 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, Self Directed Care and a variety of other state-specific names. 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).
The concept of consumer direction in care, which allows family members to be paid, now extends well beyond Medicaid. There are non-Medicaid programs, veterans programs and programs for life insurance policyholders, all of which allow for family members to be paid caregivers. As of June 2015, 49 states offer consumer direction in their Medicaid programs, 23 states allow for consumer direction in non-Medicaid elderly assistance programs, 33 states allow for some veterans care services to be self directed and life insurance policyholders programs are available in all 50 states.
Most individuals introduction to Cash and Counseling programs begins with the question: Can I get paid to be a caregiver? While many of these programs allow family caregivers to be paid, they also offer an even greater benefit; the choice of care providers. Most Cash and Counseling programs, or in more contemporary language Consumer Directed Care programs, are based on Medicaid HCBS Waivers.
Presuming the individual in need of care is already Medicaid eligible, these programs typically work as follows. 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 is made regarding how many monthly care hours are required. A benefit amount or budget is calculated using the number of care hours and cost of care for that specific 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 are given. They can hire family members as “employees”, including their adult children and in some states, even 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, 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 assisted living residences. Other states allow relatives to serve as adult foster care providers. In this situation the elderly individual moves into the home of their caregiver. Caregivers receive compensation for providing care and may receive an additional stipend for room and board (though, to be clear, not from Medicaid). Nursing home residents are not eligible to participate in Cash and Counseling programs.
Each participating state has its own requirements for their Cash and Counseling / Consumer Directed Care programs. Typically, an individual first 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. See a list of waivers and programs here.
There are some non-Medicaid programs that operate on the Cash and Counseling model as well and have less rigid financial requirements than the Medicaid programs. These can be found by exploring the program links further down this page.
Persons who have life insurance policies and wish to pay family members for their care have a different set of eligibility requirements. Learn more here.
There is also a Cash and Counseling program specifically for Veterans.
Most programs have an age requirement that participants be 65 or disabled. Marital status does not directly impact eligibility but does so indirectly through different income and asset limits.
As of 2015, programs based on the Cash and Counseling model or programs that had some element of consumer direction were available in 49 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. Generally speaking one must be a resident in the state of the program. Phrased differently, one cannot apply for a program out-of-state simply because they have different financial requirements for eligibility.
Disability requirements differ by state and by program. Generally speaking, persons that require skilled nursing, have severe mental impairments such as Alzheimer's or require assistance to perform several activities of daily living such as dressing, bathing, toileting and eating are medically eligibility for Cash and Counseling programs.
Each state and program sets its own financial eligibility requirements for its programs. Links to specific programs are available further down this page and on those pages are the financial eligibility limits for each program. However, since the majority of these programs are Medicaid based, follows are general eligibility guidelines for Medicaid.
A rule of thumb when considering Medicaid eligibility is that a single applicant is limited to approximately $2,200 / month in income and $2,000 in countable resources. Having said that, many states have higher limits and there is considerable flexibility in what is considered to be "countable income" and "countable assets". For example, a home, vehicle and a prepaid funeral plan are considered to be non-countable assets. Furthermore, in some states there is no fixed income limit but rather a determination is made if the applicant can afford their own cost of care.
Complicating Medicaid eligibility further is the fact that couples can apply together, or one spouse can apply and the other can chose not to apply. This mixed-spouse status dramatically raises the income and asset limits for Medicaid. It is recommended that couples in this situation or persons unsure of their Medicaid eligibility status consult with a Medicaid planning professional prior to completing a Medicaid application.
Benefits 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.
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.
Undoubtedly the most attractive component of Cash and Counseling programs is the fact that family members and friends can be paid as caregivers of the program participant. How this works is the program participant (the individual in need of assistance) hires their family member or friend as their personal care provider. Sometimes it is just that easy and other times fiscal intermediaries are required, payroll taxes are due and the family member has to register with their state as a licensed care provider and be subjected to a background check. Each state and program has different policies.
Most Cash and Counseling programs exclude spouses from being hired however most programs do not exclude the adult children, in-laws or grandchildren. In addition, ex-spouses are typically not excluded leading to a rather absurd situation where couples get divorced in order to care for one another.
Payment rates to the care providers are determined by the program rules. Typically care providers are paid an hourly rate several dollars per hour less than the state's hourly average for home care.
For more information, please follows the links to the specific programs below.
Depending on one’s state of residence and the specific Cash and Counseling program for which they are interested, the enrollment process varies. 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.
Having said that, it is important to remember that most Cash and Counseling programs are under Medicaid Waivers. Medicaid Waivers, unlike institutional or nursing home Medicaid, are not entitlements. These waivers have limited enrollment and waiting lists are not unusual. Time spent on a waiting list is not included in the averages mentioned above.
One typically completes a Medicaid application with the state or county Medicaid office. It is very common to seek the expertise of a Medicaid planning professional in advance to application to improve one's chances of being accepted. Once accepted by Medicaid, one can then apply for the specific Medicaid Waiver that allows for Cash and Counseling or Consumer Direction. A complete list of programs is below.
There are no costs associated with a Medicaid or Medicaid waiver application. Enrollment in Medicaid does not require monthly payments. There may be co-pay amounts but these are very minor.
For persons wishing to use a life insurance policy to pay for family members for care, the application process differs.
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.
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
Arizona Agency With Choice / Community First Choice Program
Arkansas Independent Choices Program
California In-Home Supportive Services
Colorado Consumer Directed Attendant Support Services
Colorado HCBS Waiver the Elderly, Blind, and Disabled
Connecticut Community First Choice Option
Delaware Diamond State Health Plan Plus
Florida Statewide Managed Long Term Care
Georgia Community Care Services Program Waiver (limited)
Hawaii QUEST Expanded Access (QExA)
Idaho Aged and Disabilities Waiver
Idaho Personal Care Services Program
Indiana Aged and Disabled Waiver
Iowa Elderly Waiver
Iowa Health and Disability Waiver
Kansas HCBS for the Frail Elderly
Kentucky HCB Waiver for Aged and Disabled
Louisiana Community Choices Waiver
Maryland Community Pathways Waiver
Maryland Community First Choice Program
Maryland’s Community Personal Assistance Services
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 Big Sky Bonanza
Montana Self-Directed Personal Assistance Services
Nebraska Aged and Disabled Waiver
Nebraska Personal Assistance Services
Nevada HCBW (formerly CHIP)
New Hampshire Choices For Independence
New Jersey Personal Preference Program
New Mexico Centennial Care Community Benefit
North Carolina CAP-DA Waiver
New York Consumer-Directed Personal Assistance Program
Ohio PASSPORT Waiver
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
South Carolina Community Supports Waiver
Tennessee CHOICES in Long-Term Care
Texas Community First Choice Program
Texas STAR PLUS Waiver
Vermont Attendant Services Program
Vermont Global Commitment to Health Waiver
Vermont Choices For Care (CFC)
Virginia Elderly or Disabled Waiver
Washington Medicaid Personal Care (MPC) Program
Washington Medically Needy In-Home Waiver
Washington New Freedom Program
Washington Community First Choice Option
West Virginia Aged and Disabled Waiver
Wisconsin IRIS Program
Wyoming HCBS Waiver
States Allowing Relatives as Foster Care Providers
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.