Boston College, National Program Office
Kevin Mahoney, Ph.D., National Project Director
Kristin Simone, M.M., Deputy Project Director
Lori Simon-Rusinowitz, PhD, Director of Research

The Cash and Counseling Demonstration and Evaluation (CCDE) is a policy-driven study of a consumer-directed approach to personal assistance services (PAS) for elders and younger adults with disabilities. Funded by the U.S. Department of Health and Human Services (DHHS) and the Robert Wood Johnson Foundation (RWJF), this rigorous social experiment tests the use of a cash benefit to enhance Medicaid consumers' ability to design PAS services that best meet their needs (while maintaining overall program budget neutrality). Using their cash benefit, consumers choose who provides these 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.

Working in partnership with federal agencies such as the Health Care Financing Administration (HCFA) and Social Security Administration, this true public-private project compares the cash option with traditional, agency-delivered services. The three demonstration states -- Arkansas, Florida, and New Jersey -- are offering the 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.

The evaluation, conducted by Mathematica Policy Research, 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.

Phase I of this national demonstration began in October, 1995 with selection of the evaluation contractor and demonstration states. 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 HCFA 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 CCDE promises to expand our knowledge about the use of cash benefits -- an ultimate form of consumer-directed PAS -- and inform program administrators and policymakers about future direction for state and national long-term care policies. We look forward to sharing study findings.