The IndependentChoices allowance was based on the number of hours in the Medicaid PAS benefit care plan (which was capped at 16 hours per week, unless Medicaid approved more for that beneficiary). Care plans were meant to meet consumers' care needs over and above those met with existing unpaid (or other paid) help. Beneficiaries already receiving the PAS benefit when they enrolled in IndependentChoices used existing benefit care plans that had been developed by home care agencies. IndependentChoices outreach nurses developed them for those new to the benefit. Before IndependentChoices began enrolling consumers, staff compared the number of hours of planned care with hours received for random samples of PAS users. They determined that, on average, planned hours were higher, and differences between planned and received hours of care varied across the agencies developing the plans. As a result, to maintain budget neutrality, IndependentChoices developed agency-specific discount rates: the average ratio of the cost of care received to the cost of care planned for a sample of clients of a given agency. These rates varied from 70 to 91 percent; IndependentChoices also applied a discount rate of 91 percent to plans that program outreach nurses developed. The monthly allowance was the discounted number of hours in the care plan multiplied by $8 per hour, the rate used in Alternatives.16 IndependentChoices paid for counseling and fiscal services with the savings generated by cashing out PAS care plans at $8 per hour, rather than the $12.36 per hour the Medicaid program paid agencies for PAS. The state retained the remainder ($4.36 per discounted hour) to pay the counseling/fiscal agencies.
The allowance was not large: $319 per month (or about $74 per week) on average at enrollment. Of the 1,004 consumers in the evaluation, a quarter received an allowance of $50 per week or less, and a quarter received $101 per week or more (not shown). Nonelderly adults received a somewhat higher allowance on average ($84 per week) than elderly adults ($70), perhaps reflecting the fact that many elderly consumers received some services through ElderChoices (Appendix Table A.2). Baseline measures of independence in activities of daily living and the likelihood of having an unpaid caregiver were roughly equivalent for nonelderly and elderly consumers, suggesting they had similar levels of need for PAS assistance.
The allowance could be used only to purchase items included in the spending plan. The consumer could request up to 10 percent of the allowance for incidental expenses that could not readily be invoiced, but the nature of these expenses were specified in the plan (for example, taxi fare). Allowable purchases generally had to promote independence or increase mobility.
More than 80 percent of consumers developed a spending plan and started receiving the allowance within three months of enrolling in IndependentChoices; this percentage was somewhat higher for nonelderly consumers (86 percent, compared with 79 percent for elders) (Appendix Table A.10a and Table A.10b, top panel).17