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Cash & Counseling


The NRCPDS builds on lessons learned as the National Program Office for Cash & Counseling, a successful decade-long effort to introduce participant-directed programs into 15 state Medicaid programs.

Model Overview

The Cash & Counseling grant program has introduced participant-directed programs into the Medicaid programs of 15 states. The National Resource Center for Participant-Directed Services (NRCPDS) served as the national program office for this successful effort from 1998 to 2009.

Cash & Counseling gives people with disabilities, including older adults, the option to manage a flexible budget and decide what mix of goods and services best meet their personal care needs. Participants may use their budget to hire personal care workers, purchase items and make home modifications that help them live independently. Those participants who don't feel confident making decisions on their own may appoint a representative to make decisions with or for them.

Project Overview

In 1998 a three-state demonstration was conducted to compare the Cash & Counseling participant-directed model with the traditional agency-directed approach to delivering personal-assistance services. The success of the original demonstration led funders to grant an expansion of the Cash & Counseling program.

The vision guiding this expansion was the promise of "a nation where every state will allow and even promote a participant-directed individualized budget option for Medicaid-funded personal-assistance services." Although the replication state grants ended in 2009, the 15 Cash & Counseling states continue to operate their projects. The Cash & Counseling original demonstration and replication projects were sponsored by The Robert Wood Johnson Foundation, the Office of the Assistant Secretary for Planning and Evaluation in the United States Department of Health and Human Services, and the Administration on Aging.

Lessons Learned

We worked with Mathematica Policy Research, Inc. to conduct five years of research on how each of the three Cash & Counseling demonstration states implemented its program, and on how the programs have affected the participants, their paid and unpaid caregivers, and the costs to Medicaid. Here are some of our key findings:

  • Cash & Counseling significantly reduced the unmet needs of Medicaid participants who require personal assistance services.
  • Cash & Counseling participants experienced positive health outcomes
  • Cash & Counseling improved quality of life for participants and their caregivers
  • Cash & Counseling did not result in misuse of Medicaid funds or abuse of participants
  • Medicaid personal care costs were somewhat higher under Cash & Counseling, mainly because enrollees received more of the care they were authorized to receive
  • Increased Medicaid personal care costs under Cash & Counseling were partially offset by savings in institutional and other long-term-care costs
  • Cash & Counseling need not cost more than traditional programs if states carefully design and monitor their programs
  • Directly hired workers under Cash & Counseling and home care agency workers felt equally prepared to do the job expected of them

Cash & Counseling helps participants direct and manage their personal assistance services according to their own specific need.  Our goal is to expand this proven model to more states, allowing thousands more older adults and people with disabilities to have choice and control over the services they receive.

For more information:

  • See Tools & Resources for the final report for the original demonstration and replication projects.
  • Visit for a comprehensive listing of Cash & Counseling tools and resources.
  • Read the Handbook on Participant Direction, which features essential information for designing participant-directed services.
  • Check out our data and analysis tools to access data from the original demonstration.