Page Reviewed / Updated - Apr. 2016
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 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 California, “In Home Supportive Services” and in Michigan, the “Choice Waiver”.
The Cash & Counseling Program began as a pilot Medicaid program in fifteen 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 and long term care insurance policyholders, all of which allow for family members to be paid caregivers. Currently forty-five states offer consumer direction in their Medicaid programs, twenty-three states have consumer direction in non-Medicaid or non-profit assistance programs, thirty-four states allow for some veterans’ care services to be self-directed and life and long term care insurance policy conversion programs are available in all 50 states.
Most people are introduced to Cash and Counseling programs when asking 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 program that offers Cash and Counseling / Consumer Directed Care has its own eligibility requirements.
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.
All but eight states exclude spouses from being hired. 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.
California Paid Family Leave
Colorado Home Care Allowance
Connecticut Choices at Home Project
Connecticut Statewide Respite Care Program
District of Columbia Caregivers’ Institute
Hawaii Chore Services Program
Iowa Senior Living / Case Management Program
Kansas Senior Care Act
Kentucky Hart-Supported Living Program
Kentucky Personal Care Attendant Program
Maine Home Based Care
Massachusetts HCP and ECOP Programs
Minnesota Alternative Care Program
Nebraska Disabled Persons and Family Support
New Jersey Assistance for Community Caregiving
New Jersey Family Leave Insurance
New Jersey Statewide Respite Care
New York Expanded EISEP Program
North Carolina In-Home Aide Services
North Dakota SPED and Ex-SPED Programs
Pennsylvania Options Program
Rhode Island Temporary Caregiver Insurance
Texas: Community Attendant Services Program
Texas CCAD Program / Client Managed Personal Attendant Services
Texas DADS Services to Assist Independent Living
Texas In-Home and Family Support 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
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
District of Columbia EPD Waiver / Services My Way
Florida Statewide Managed Long Term Care
Georgia Community Care Services Program Waiver (limited)
Hawaii QUEST Expanded Access (QExA)
Idaho Aged and Disabilities Waiver
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
Montana HCBS Waiver
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
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 (Note this list may not be exhaustive)
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.