Program Structure Matters: A State-by-State Look at Consumer-Directed Programs

As we mentioned in our prior blog, we are examining four main consumer-directed programs. The first is New York’s Consumer Directed Personal Assistance Program (CDPAP). This program was established in the 1990s and is a pioneering model that gives Medicaid recipients complete control over their caregiving. Like all consumer-directed programs, participants can hire family members or friends as caregivers, which provides autonomy and allows individuals to receive care from who they want, when, and where they want. It is also particularly valuable for those facing language or cultural barriers, as it allows them to select caregivers who align with their personal needs and preferences. 

The CDPAP program in New York is undergoing a major overhaul as the Department of Health and the Governor are moving towards consolidating the services of about 700 CDPAP providers into a single, co-employer model of fiscal intermediary support.  This change is projected to bring about significant savings to the state, but it is also fraught with considerable risks. As advocates, we are concerned about a variety of aspects of the new program, including:

1. The proposed format eliminates consumer choice of providers. This has proven to be a stumbling block when other states implement similar programs. In Pennsylvania, for example, the consolidation of Fiscal Intermediaries resulted in over 13,000 consumers leaving the consumer-directed option for the agency option and, in the process, giving up control of their services to a third party.
2. The selected provider has a long history of infractions and poor services in other states.  The idea that a single provider can support over 250,000 consumers and manage over 350,000 caregivers seems like it will come with many problems. As advocates, we are very concerned about the capacity and risks associated with the suffering of so many vulnerable consumers.
3. The transition to the new program is very short, resulting in consumers not receiving services and caregivers not getting paid.

Launched in 2002, Colorado’s Consumer-Directed Attendant Support Services (CDASS) is another program that provides participants with unparalleled control. Under this program, consumers work with case managers to determine needs, including homemaker services, personal care, and health maintenance. Under CDASS, consumers can use their Health First Colorado dollars to pay the attendant of their choice rather than a home health or personal care agency. They are responsible for managing their provider. The added flexibility of CDASS enables individuals to manage the services they need to live independently and to participate in the community more fully.

Pennsylvania also offers a program under OLTL’s Home and Community-Based Waiver Services and ACT 150. Pennsylvania’s consumer-directed program allows individuals to employ a personal attendant rather than arranging for a worker through an agency. Employers must meet the income guidelines defined by OLTL’s Medicaid Waiver Services, and like other states, allows consumers to choose the services they need and who will provide them. 

Oregon’s Consumer-Employed Provider Program (CEP) puts an emphasis on emphasizing direct participant oversight of caregiving services. Medicaid recipients can hire, supervise, and terminate caregivers, granting them full authority over their care. Through the program, consumers can get personal care assistance, homemaker services, non-medical transportation, health-related tasks like wound care and insulin injections, and medication and oxygen management. State support is integral to the program’s success, as it handles enrollment, payroll, tax compliance, and legal obligations. Another OR Medicaid program is called the Independent Choices Program (ICP). Through this program, seniors can self-direct their long-term care, including hiring their spouse as a caregiver. One way this program differs from the CEP Program is that the state plays a more minor administrative role. Instead of the state paying caregivers, consumers in this program given receive a monthly cash benefit with which to pay their selected caregivers. 

While these programs all have the same theoretical goal of providing choices to the consumers, it is important choices to consumers; it is important to note that controlling who provides services and what services are provided is not where choice should end. Fiscal intermediaries play a significant role in the administration of these consumer-directed programs and impact their success. When it comes to choice; it also needs to extend to the administration of these programs.