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Objective. To uncover lessons from abroad for Community Living Assistance Services and Supports (CLASS), a federally run voluntary public long-term care (LTC) insurance program created under the Accountable Care Act of 2010. Data Sources. Program administrators and policy researchers from Austria, England, France, Germany, and the Netherlands. Study Design. Qualitative methods focused on key parameters of cash for care: how programs set benefit levels; project expenditures; control administrative costs; regulate the use of benefits; and protect workers. Data Collection/Extraction Methods. Structured discussions were conducted during an international conference of LTC experts, followed by personal meetings and individual correspondence. Principal Findings. Germany's self-financing mandate and tight targeting of benefits have resulted in a solvent program with low premiums. Black markets for care are likely in the absence of regulation; France addresses this via a unique system ensuing legal payment of workers. Conclusions. Programs in the five countries studied have lessons, both positive and negative, relevant to CLASS design. Key Words. Cash for care, long-term care, aging, disability, health care financing, The 2010 Affordable Care Act (ACA) establishes the Community Living Assistance Services and Supports (CLASS), a publicly sponsored long-term care (LTC) insurance plan financed through voluntary premium payments. Because this [...]

Objective. This paper reflects on the progress of the original Cash and Counseling states, and shows how this model has spread, how it has evolved over time, and what is left to improve. It then discusses the generalizability of the Cash and Counseling approach beyond long-term care and ventures some thoughts on what still needs to be learned. Finally, this paper suggests some of the contingencies that could affect the diffusion of this innovation. Data Sources/Study Setting. Drawing from ten years of experiences with the fifteen Cash and Counseling states, plus their analyses of current trends and future opportunities and threats, the framers of the Cash and Counseling model reflect on future directions. Study Design. This paper is essentially a policy-driven analysis of how the Cash and Counseling model has been sustained and disseminated, how it is likely to develop, and what still needs to be learned. Principal Findings. The basic Cash and Counseling model appears adaptable to different state environments and populations, but that hypothesis will be severely tested as more and more states seek to replicate. As one step to promote flexibility while capturing and preserving the essence of the model that led to such promising research results, the Cash & Counseling National Program Office developed a "Vision Statement". Conclusions. The Cash and Counseling approach is not for everyone, but it is clearly a choice many participants desire. Its development merits monitoring. Key Words. Consumer direction, federal and state policy, cash and counseling, The Supreme Court's 1999 Olmstead decision made it clear that state long-term care systems must provide a continuum of services that allows people to live where and how they want. [...]

Objective. The Cash and Counseling Demonstration and Evaluation (CCDE) was designed as an experiment in shifting the paradigm in home and community-based long-term care from a professional/bureaucratic model of service delivery to one emphasizing consumer choice and control. The experimental intervention was an individualized budget offered in lieu of traditional Medicaid-covered services, such as agency-delivered aide services or a plan of care developed and coordinated by a professional case-manager, which typically involves authorization for several different providers to deliver a range of services. Within the spending limits established by their budgets, program participants were largely free to choose the types and amounts of paid services and supports they judged best able to meet their disability-related personal assistance needs. Study Population. Medicaid beneficiaries in selected states who volunteered to participate. In all of the participating state Medicaid programs, beneficiaries eligible to participate included elders and younger adults with chronic disabilities and, in one state, adults and children with mental retardation/developmental disabilities could also participate. Minor children and adults with cognitive impairment could participate via representatives (family or friends who agreed to assist them in managing their services or to act as their surrogate decision-makers). Data Sources. Members of the CCDE management team describe the rationale for and implications of key design decisions. Study Design. Key design decisions included the choice of research methodology (random assignment of CCDE participants in each state to treatment and control groups), selection of the state sites (AR, FL, NJ, NY), and the need for the CCDE to comply with federal waiver requirements for Medicaid research and demonstration projects. Principle Findings. The CCDE design was successfully implemented in three of the four state Medicaid programs selected for participation. Conclusions. The successful implementation of the CCDE (results from the evaluation are reported elsewhere) led to replication efforts in other states. The CCDE also inspired changes in Medicaid law and policy, including the 2002 "Independence Plus" Initiative by the Centers for Medicare and Medicaid and sections of the Deficit Reduction Act of 2005 intended to promote consumer-direction in Medicaid. Key Words: Consumer direction, Medicaid home and community-based services, personal assistance services., Coverage of personal assistance services for Medicaid program participants with long-term functional disabilities has been available since the late 1960s, but, during the 1980s, coverage options were expanded and more [...]

The 'Cash and Counseling' Demonstration/Evaluation is a large-scale public policy experiment designed to test the feasibility and assess the advantages and disadvantages of a consumer-directed approach to the financing and [...]