1. Cash & Counseling 101

2. Cash & Counseling: Program Overview  Funders  The Robert Wood Johnson Foundation  US DHHS/ASPE  Administration on Aging  Waiver and Program Oversight  Centers for Medicare and Medicaid Services  National Program Office  Boston College Graduate School of Social Work  Evaluator  Mathematica Policy Research, Inc.

3. Original Cash & Counseling Demonstration Overview Demonstration States  Arkansas, Florida, New Jersey  Study Populations  Adults with disabilities (Ages 18-64)  Elders (Ages 65+)  Florida only: Children with developmental disabilities  Feeder Programs  Arkansas and New Jersey: Medicaid personal care option programs  Florida: Medicaid 1915c Home and Community-Based long-term care waiver programs

4. Basic Model for Cash & Counseling  Step 1: Consumers receive traditional assessment and care plan  Step 2: A dollar value is assigned to that care plan  Step 3: Consumers receive enough information to make unbiased personal choice between managing individualized budget or receiving traditional agency- delivered services

5. Basic Model for Cash & Counseling  Step 4: Consumer and counselor develop spending plan to meet consumer’s personal assistance needs  Step 5: Cash allowance group provided with financial management and counseling services (supports brokerage)

6. Original and Expansion Cash & Counseling States

7. Receiving Monthly Allowance at 9 Months ( Treatment Group Members Living in Community) Non-Elderly Adults Percent AR FL NJ AR FL NJ FL Elderly Adults Children

8. Receiving Paid Assistance at 9 Months Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL **

9. Very Satisfied with Overall Care Arrangements Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL **

10. Had an Unmet Need for Help with Personal Care Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL ** * *

11. Contractures Developed or Worsened Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL ** * *

12. Very Satisfied with Way Spending Life These Days Non-Elderly Adults *, ** Significantly different from control group at.05,.01 level, respectively. Percent T C AR Elderly Adults Children T C FL T C NJ T C AR T C FL T C NJ T C FL ** *

13. Informal Caregivers Very Satisfied with Overall Care *, **, *** Significantly different from control group at.10 (*),.05 (**), or.01 (***) level. Percent Adults Children TT T T C C C C ARFL NJ FL ***

14. Informal Caregivers Experienced Less Emotional Strain Percent Adults Children *, **, *** Significantly different from control group at.10 (*),.05 (**), or.01 (***) level. TT T T C C C C ARFL NJ FL *** **

15. Informal Caregivers Experienced Less Physical Strain Percent Adults Children *, **, *** Significantly different from control group at.10 (*),.05 (**), or.01 (***) level. TT T T C C C C ARFL NJ FL ***

16. Informal Caregivers Experienced Less Financial Strain Percent Adults Children *, **, *** Significantly different from control group at.10 (*),.05 (**), or.01 (***) level. TT T T C C C C ARFL NJ FL ***

17. Working Conditions Directly HiredAgency Hourly Wage AR FL and NJ $6.00 $10.00 $6.30 $9.00 Receives Fringe Benefits 2 to 5%17 to 24% Very Satisfied with Wages and Benefits 41 to 50%19 to 23% Very Satisfied Overall 79 to 85%69 to 83%

18. Training and Preparedness of Directly Hired Workers  Half trained in personal care or routine health care On the other hand—  Felt well-informed about care recipient’s condition ( ~ 90%)  Felt fully prepared for job (>90%)  Injuries and physical strain similar to agency workers providing equal hours of care

19. Effects on Medicaid PCS/HCBS Expenditures—Year 1  Significantly Higher for Treatment Group in Each State  In AR and NJ, Mainly Because Control Group Received Substantially Less Care Than Authorized  In FL, Mainly Because Children and Adults With Developmental Disabilities Got Larger Benefit Increases After Assigned to Treatment Group

20. Effects on Medicaid PCS/HCBS Expenditures—Year 1 ARFLNJ Adults Nonelderly+124% ($3,005)** +20% ($3,696)** +21% ($1,946)** Elderly+88% ($2,021)** +4% ($433) +12% ($1,241)** Children--+26% ($3,319)** -- **Significantly different from zero at.01 level.

21. Effects on non-PCS Medicaid Expenditures  Other Medicaid Costs Moderately Lower For Treatment Group in Each Age Group in All Three States  The Best Example: In AR, Compared to Control Group, Treatment Group Had 40% Fewer Admissions to Nursing Facilities in Second Year

22. Effects on non-PCS Medicaid Expenditures—Year 1 ARFLNJ Adults Nonelderly-17% (-$1,743)* - 6% (-$369) -7% (-$1,132) Elderly-4% (-$320) -5% (-$296) -5% (-$413) Children---15% (-$2,439)* -- *Significantly different from zero at.05 level.

23. Effect on Total Medicaid Costs  In AR, No Significant Difference by End of Year 2 Reductions in NF and other Waiver Costs Off-Set Increase in Personal Care Costs  In NJ and FL, Costs Up 8-12%, But States Learned How to Control Costs  Higher Costs in AR and NJ Due to Failure of Traditional System

24. Effect on Total Medicaid Costs— Year 1 vs. Year 2 ARFLNJ All Adults Year 1 Year 2 +14%** +5% +9% +12%** +4% +12%** Children Year 1 Year 2 --+3% +8% -- **Significantly different from zero at.01 level.

25. Policy Implications  Can increase access to care  Greatly improves quality of life (all ages)  Caregivers also benefit greatly  States may be concerned about costs But have learned how to control them