A Compendium of Current Federal Initiatives in Response to the Olmstead Decision. Cash and Counseling Demonstration and Evaluation


Funding Organizations:

  • Office of the Assistant Secretary for Planning and Evaluation (ASPE)
  • Robert Wood Johnson Foundation (RWJ)

Implementing Organizations:

  • Boston College Graduate School of Social Work--National Program Office for the Cash and Counseling Demonstration
  • Mathematica Policy Research, Inc. (MPR)--evaluation contractor


To test whether a cash benefit enhances the ability of Medicaid-recipient elders and younger adults with disabilities to design personal assistance services that best meet their needs (while maintaining overall program budget neutrality).


The concept behind a cash benefit--a consumer-directed approach--is that consumers choose who provides very personal and essential services (help with bathing, eating, dressing, etc.), as well as when and how they are provided. For example, consumers may hire a friend or relative, who knows their preferences, to help them on evenings or weekends when agency services may be unavailable. Consumers are also able to use their benefit to buy other services that may increase their independence (e.g., transportation, home modifications, assistive devices). Counseling and bookkeeping are offered to help consumers manage their services.


Phase I of this national demonstration began in October 1995 with selection of the evaluation contractor and demonstration states. Three demonstration states--Arkansas, Florida, and New Jersey--are offering cash-option to elders (over 65 years old) and adults with disabilities (ages 18-64). Children with developmental disabilities are also included in Florida. Arkansas and New Jersey are cashing out services from the Medicaid optional personal care benefit, while Florida is including services from the state's Home and Community-Based Services waiver.

Phase II (October 1996-November 1998) included background research (focus groups and telephone surveys) to determine consumers' preferences for a cash-option or traditional services, completion of a Health Care Financing Administration Medicaid 1115 waiver application, coordination with other federal agencies regarding the impact of the cash benefit on eligibility for other major programs, and development of demonstration state infrastructures for outreach, counseling, and fiscal intermediary services.

Phase III began in December 1998 when Arkansas enrolled the first cash-option consumers. New Jersey began enrolling consumers in November 1999 while Florida began enrollment in May 2000. Each state will have open enrollment for at least one year and consumers will be followed for one year (with a promise of two years of cash). Interim project reports will be developed during program implementation, and the final report will be completed one year and three months after data collection is completed.

The evaluation randomly assigns consumers interested in the cash-option to treatment and control groups. This comprehensive evaluation focuses on consumers' service utilization and preferences, quality of care, and service costs as well as issues related to paid and informal workers. A process evaluation also documents how the cash-option was implemented in each state and identifies environmental factors that can explain program effects. Project counselors will also provide feedback on their experience with cash-option consumers. Finally, a qualitative study in each demonstration state will provide an in-depth view of how the cash-option team (consumer/representative, worker, and counselor) work together.

Contact Information:

For contact information for the participating agencies, visit the program website: http://www.inform.umd.edu/EDRes/Colleges/HLHP/AGING/CCDemo.

Other information on this project is available from ASPE's website: http://aspe.hhs.gov/_/office_specific/daltcp.cfm

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