1 
Department of Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
COST  SHARING  UNDER

THE  OLDER AMERICANS  ACT

~~SERWC$$ 
&  /+
**  ? 
#  JUNE  GIBBS BROWN 
~ 
Inspector  General 
s
% 
%++ # 
MAY  1996 
~>daa
OEI-05-954XU70  OFFICE  OF  INSPECTOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amenti  ia to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit SeMces, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE  OF AUDIT  SERVICES 
The OIGS Oflice of Audit SeMces (OAS) provides all auditing seMces for HHS, either by 
conducting audits with its own audit &sour&s or by overseeing-audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficienq  throughout  the Department. 
OFFICE  OF INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
cxmtrol units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF EVALUATION  AND INSPECHONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluation  (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations cmtained  in these inspection 
reports generate  rapi~  accurate, and upto-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This inspection waa cxmducted in Region V, under the guidance of William C. Moran, 
Regional bpector  Genera~ and Natalie Coen, Deputy Regional Inspector General. 
tinducting  the inspection were: 
Region V  Headquarters 
Jean DuFre.sne  David Wright  d 
Department of  Health and Human Services 
OFFICE  OF 
INSPECTOR  GENEML 
COST  SHARING  UNDER

THE  OLDER AMERICANS  ACT

JUNE  GIBBS BROWN 
Inspector  General 
MAY  1996 
OEI-05-95-00170  EXECUTIVE  SUMMARY

To  describe  States  current  practices  and  discuss  implementation  issues concerning  cost 
sharing  for services  to older  persons  under  Title  111of the  Older  Americans  Act. 
Background 
Through  the  Administration  on Aging (AoA),  the  Older  Americans  Act  (the  Act)  of 
1%5  authorizes  financial  assistance  to States  for setices  to older  persons.  Setices 
provided  under  Title  III of the  Act  include,  but  are  not  limited  to, nutrition, 
transportation,  and  in-home  personal  and  medical  services.  The  AoAs programs 
reach  elderly  citizens  through  a wide nework  of public  and  private  agencies,  including 
local  area  agencies  on aging and  service  providers. 
In the  past,  States,  area  agencies  on aging, and  setice  providers  have  been  allowed  to 
ask recipients  of Title  111funded  services  for voluntary  contributions,  to help  cover  the 
cost of the  sexvice.  Mandato~  charges  for the  federally  finded  portion  of these 
setices  is not  allowed,  although  States  can  charge  for all or part  of their  portion  of 
the  funded  sewice.  Known  as cost sharing,  these  charges  have  helped  some  States 
maintain  or expand  services  to recipients.  In the  current  reauthorization  of the  Act, 
AoA  proposed  amendments  that  would  allow States,  area  agencies  on aging, and 
service  providers  to charge  for some  of the  Title  III funded  senrices. 
The  AoA  requested  information  on current  cost sharing  activities  within  the  States. 
We  surveyed  57 States  and  territories  to obtain  the  information  in this report. 
FINDINGS  AND  ISSUES 
Alf Statacolld  vohuwnycon@uticw  and36State.s  makzweofcatshan  pmgranm
-)  * 
qxrienawih  thaepnlctices  willafectth ?irlwrdkssmti  -
Zwmcmzsharing 
Thirty-six  States  reported  to us that  they  have  some  sort  of cost  sharing  program  for 
setices  to elderly  people.  These  programs  vary considerably.  They  may use State 
Units  on&ixI&other  State  agencies,  area  agencies  on aging, and  local  semice 
provider$  or a combination  of the  above,  to bill, colle~  and  cany  out  other 
responslMlities.  SeMces  cost shared  also vary greatly,  but  in-home  personal  semices 
and  adult  day care  programs  are  the  most  commonly  reported  cost shared  semices. 
As with  cost  sharing  States  vary greatly  in their  voluntary  collection  activities.  After 
nutrition  semices,  transportation  is the  most  common  service  for which voluntary  funds 
are  collected. 
i  The  extent  of area  agency  on aging involvement,  and  how fees  are  determined, 
including  the  use  of sliding-scale  fee  schedules,  will be  important  to effectively 
implementing  Title  III cost sharing.  Sliding-scale  fee  schedules  help  address  the 
fairness question  of cost  sharing,  since  recipients  are  asked  to pay only what  they  can 
afford,  based  on their  income. 
State  respondents expressd  a variety ofopinions regaling  the potentialities  of  cost shaing 
lltik  III fiuuik  Opihions mnged @m  great sqyxw  fortheidkttqogreat cautioti 
One-half  of State  respondents  believe  they  can  expand  the  provision  of some  services 
to recipients  through  cost  sharing.  They  also said  that  successful  implementation  will 
depend  in part  on how the  cost sharing  is explained  to, and  thus  accepted  by 
recipients.  However,  some  respondents  expressed  great  concern  that  cost  sharing 
might  encourage  some  service  providers  to reach  out  to recipients  better  prepared  to 
share  costs,  thus  undermining  targeting  efforts  to low-income  elderly. 
Cbst stig  with llth IIIjhdY  miws  accoumtzbi@  and ovem&t  quedons  for Statq 
azea agencies on agihg  and service proviiem 
Nine  States  with  cost  sharing  programs  currently  verifj  the  reported  income  of 
recipients  receiving  services.  Most  cost sharing  programs  use  self-declaration  by 
recipients.  Some  respondents  were  concerned  that  asking  recipients  to reveal  their 
income  might  embarrass  or  anger  them  to such  an extent  that  they will drop  out  of 
programs.  Other  respondents  questioned  the  overall  cost  effectiveness  of income 
verification  versus  self-declaration  by recipients. 
Cost  sharing  will also require  billing  and  collection  activities  that  might  not  currently 
exist, including  policies  and  procedures  on payment  default  by recipients.  States  seem 
to have  few written  policies  in this area  so far.  General  policies  range  from  strict 
service  termination  to never  terminating  services  regardless  of payment  default. 
IMPLEMENTATION 
If Congress  enacts  legislation  to permit  cost sharing,  the  AoA  will need  to carefully 
consider  their  direction,  oversight,  and  technical  assistance  to States,  area  agencies  on 
aging,  and  service  providers.  Special  attention  will be  needed  concerning  the  use  of 
fee  schedules,  income  declaration  and  verification,  billing and  collection  activities,  and 
policies  on payment  default.  Some  States  will need  more  help  than  others. 
The  AoA  provided  comments  about  this report;  they  can be  found  in Appendix  C. 
The  AoA  states  that  the  information  in the  report  has provided  them  with  the 
necessary  background  information  required  to assess  cost sharing  language  in 
reauthorization  bills in both  the  House  and  the  Senate.  The  AoA  also  anticipates  that 
the  survey  data  will provide  baseline  information  to develop  program  policy  and 
technical  assistance  for State  agencies  administering  programs  under  the  Older 
Americans  Act. 
ii  TABLE  OF  CONTENTS

PAGE

EXECUTIVE  suMMARY

INTRODUCHON  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

FKNDINGS AND  ISSUES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

States  current  practices  will impact  on future  cost  sharing  . . . . . . . . . . . . . . . .  4

 
State  respondents  expressed  variety  ofopinions  . . . . . . . . . . . . . . . . . . . . . . . . 8

 
Cost  sharing  raises  accountability  and  oversight  questions  . . . . . . . . . . . . . . . . .  9

 
IMPLEMENTATION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11

APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

kSumeys  and  Responses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l

B:  Examples  ofState  Forms  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-1

C  Agency  Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..C-l
 INTRODUCTION

To describe  States  current  practices,  and  discuss  implementation  issues concerning 
cost sharing  for sewices  to older  persons  under  Title  III of the  Older  Americans  Act. 
Background 
OkkTAm&canr  Actandservi6eY  toe&iymc@iews 
The  Older  Americans  Act  (the  Act)  of 1%5  (PL89-73)  created  the  Administration  on

Aging (AoA)  which  provides  financial  assistance  to States  for social  service  and

nutrition  programs  for older  persons  under  Title  111. Grants  are  allotted  to States

based  on the  size of the  60 plus population.  States  submit  plans  which  must be

approved  by AoA  Regional  offices before  funds  are  allocated.

The  AOAS 10 regional  offices  assist States  in developing  responsive  community-based

comprehensive  and  coordinated  sewices  for elderly  recipients  throughout  the  nation.

The  AOAS programs  reach  the  elderly  through  a network  of public  and  private

agencies,  including  59 State  and  Territorial  State  Units  on Aging (SUAS),  and  their

approximately  675 local area  agencies  on aging  (AAAs),  as well as over  100 Native

American  tribal  organizations,  and  approximately  27,000 local  sewice  providers.

Part  IIIB  of the  Act  provides  funds  for a variety  of supportive  services,  including

health,  transportation,  and  legal  assistance.  The  Fiscal  Year  (FY)  1996 requested

appropriations  for  Part  IIIB are  approximately  $307 million.  Requested

appropriations  for Part  IIIC, which funds  nutrition  sexvices, including  both  congregate

and  home-delivered  meal  programs,  are  approximately  $470 million.  Part  IIID

provides  for non-medical  in-home  sewices  for frail older  individuals.  Requested

appropriations  for Part  IUD are  approximately  $9 million.

Currently,  SUAS, AAAs,  and  service  providers  are  not  permitted  to charge  mandatory

fees  to individual  users  of semices  for federally  funded  Title  III semices.  The

solicitation  and  collection  of voluntary  contributions  from  recipients  for these  semices

is permitted.  Nutrition  services  generate  the  most  money  in voluntary  contributions;

supportive  sewices,  especially  in-home  sewices,  generate  the  least.

The  SUAS and  depending  on State  laws, the  AAAs  and  service  providers  may charge

mandatory  fees  to recipients  for those  seMces  which are  provided  through  State  or

local  funds.  These  seMces  may parallel  or enhance  the  federally  funded  scmices  such

as homemaker  selvices.  For  example,  one  homemaker  visit to an older  American  may

cost a total  of $20.00.  The  AoA  grant  may fund  half of that  visit while  State  or local

funds  will pay for the  other  half.  Under  current  regulation,  the  SU~  AAA  or service

provider  may only mandatorily  charge  for a portion  of the  State  or locally funded

1  $10.00.  Only a voluntary  contribution  can  be accepted  for the  Federal  portion  of the 
service  charge. 
There  are  some  sendces  in the  States  provided  through  Federal  Medicaid  waivers  or 
Social Security  Block  Grants,  which might  include  a fee  charged  to the  recipient  of the 
semice.  The  SUA  may or may not  administer  the  programs  funded  through  these 
Federal  sources. 
Generally  referred  to as cost sharing,  charging  for some  sexvices helps  some  States 
expand  semices,  or keep  services  in place  as budgets  are  cut  (GAO  1989).  Most 
recipients  of services  who are  required  to cost share  are  not  opposed  to paying  for 
semices  as long as the  charge  is fair  (OIG  1990). 
Rrposed  kgMUive  amenbwm  todknvfmc(x-g 
In past  re-authorizations  of Title  111funding,  the  Administration  has requested  cost 
sharing  for certain  federally  funded  semices.  The  Congress,  however,  has never 
approved  the  cost sharing  provisions.  The  AoAs current  re-authorization  bill once 
again  requests  provisions  for cost sharing.  As summarized,  AoA  requests  that  sections 
306 and  307 (State  Plan  requirements)  of the  Act be amended  to give States  the 
option  to require  or permit  cost sharing  for some  semices  under  State  or area  plans. 
Under  the  proposed  amendmen~  cost sharing  could  not  be  required  for information 
and  assistance.  Other  services  funded  with Title  111funds will be open  to cost sharing; 
States  will choose  which,  if any, of these  services  they  may choose  to cost share. 
The  AoA  believes  that  Congress  will pass some  form  of cost sharing  amendments  in 
this years re-authorization  of Title  III funds.  The  AoA  requested  this study  in order 
to obtain  information  that  will help  them  more  effectively  implement  recipient  cost 
sharing  for some  Title  III setices.  In particular,  the  AoA wanted  to know what 
current  State  activities  regarding  cost sharing  are,  and  how cost sharing  for Title  III 
funds  might  affect  their  current  cost sharing  activities. 
Mlm-IoDomGY 
The  information  in this report  was obtained  by surveying  57 States,  the  District  of

Columbia  (DC)  and  territories  (all referred  to as States)  through  a mail  suwey.  Two

sumeys  were  sent  out.  The  first was a small  two-page  sumey  to obtain  initial

information  about  whether  the  State,  or any MA  or service  provider  within  the  State,

conducted  any cost  sharing  with State  funds  for setices  provided  to elderly  recipients.

The  second  survey was an  in-depth  suwey  with three  sections.  The  first section  asked

questions  and  requested  documentation  about  the  States  current  cost-sharing

activities,  the  second  section  concerned  States/AAAS/service  providers  activities

regarding  the  collection  of voluntary  contributions  for Title  III funds,  and  the  third

Section  asked  for State  respondents  thoughts  on how cost sharing  with Title  111funds

might  affect  their  current  activities,  and  if allowed,  how best  to implement  Title  III

cost sharing.

2  Fifty-three  States  returned  the  initial  suxvey.  From  this survey, 36 States  indicated  that 
their  State  conducted  some  sort  of cost sharing  activity. 
A total  of 50 States  returned  the  main  sumey  in time,  and  correctly,  to be  included  in 
our  analysis  of the  data.  Within  the  main  survey,  31 States  responded  to Section  I 
regarding  current  cost sharing  activities.  Forty-nine  States  responded  to Section  II, 
and  forty-nine  States  responded  to Section  III.  It should  also be  noted  that  not all 
States  responded  to all questions  within  the  survey, so individual  questions  have 
different  response  rates.  (See  Appendix  A for a copy of the  main  survey with 
responses.) 
3
 FINDINGS
AND  ISSUES 
All States  collect  voluntary  contributions  and  two-thirds  of the  States  make  use of cost 
share  progamss  States  specific  experiences  with  these  practices  will affect  their 
readiness  to implement  Title  III cost sharing. 
Sen&t?scart  shad 
Thirty-six  States  reported  to us that  they have  some  sort  of cost share  program  for 
sexvices to elderly  people.  These  programs  vary in terms  of services  cost shared,  and 
in SU&  ~  and  sewice  provider  responsibilities  for billing, collection,  and  other 
procedures.  Table  1 alphabetically  lists the  States  which reported  to us that  they cost 
share,  and  the  semices  for which they  do this.  In-home  personal  services  and  adult 
day care  programs  are  the  most  commonly  reported  cost shared  semices. 
Sl?rPicesM4dtUohllwuyClwduion  dkctbls 
All of the  States  collect  voluntary  contributions  for some  setices.  As with cost 
sharing,  States  vary greatly  in their  voluntary  collection  activities.  Table  2 
alphabetically  lists the  States  and  the  semices  for which they  collect  voluntary 
cmtributions.  After  nutrition  services,  transportation  is the  most  common  semice  for 
which voluntary  funds  are  collected. 
AM  invdvemenf 
In 13 States,  all of the  AAAs  are  involved  in cost sharing  programs  and  activities.  In 
seven  other  States,  some  of the  States  AAAs  are  involved  in cost sharing  programs, 
either  because  AAAs  may choose  whether  to cost share,  or because  of pilot  projects 
or other  special  programs  within  the  State. 
In  11 States  cost sharing  for services  occurs  without  any AAA  involvement.  In these 
cases  the  State  either  contracts  directly  with  local providers,  or in a few cases,  the  cost 
sharing  is canducted  through  an entirely  different  State  agency.  In these  cases,  the 
SUA  also has no current  experience  with cost sharing  practices. 
In terms  of conducting  cost sharing  with Title  111funds,  current  AAA  involvement  with 
cost sharing  programs  will be  important  because  Title  III funds  are  generally  funneled 
out  to the  local  providers  through  the  AAAs.  (An  exception  to this case  will be  5 
States  where  the  State  agency  is also  the  States  only M) 
4
 States  that  Cost  Share,  By Type of Service 
Table  I 
WfltJregate  home del.  in-home 
in-home  adult day  transpt.  legal  case 
meal  !  meal  I  medical  pemonal  care  I  asst.  ~ mgt. other
AcCTKA  I!   PP   PP   PP   PP   eCss  PP  PP  CPs
  CS (respite)

P  Cs  es  es  es  P P es

IHGDDICA    ~  PPPP  ,   ePPPs     ePs  eeesss   ePPPs    eePPss 
   PPP   PPP
   PP((hesecaottfht) p
 romotion+)

IL  es 
IN  P  es  es  eCss   eess   ePs  P c:  P(senior wmpanion)
KS 
es 
IKAYl   PP   eess   PP  eess   ePs  PP  PP  PP   CS (respite+)
MMDA   PP   ePs   eess   eess   eess  Cess   CPs   c!  CS (alzheimer)
ME  P  P  es  Cs  es  P P es
MN  P  P  es  es  es  es P P
Mo  P  P  es  es  P P P P 
ND  ?  ?  ?  ?  ? ? ? ?? 
NE  ?  ?  7  ?  7  ?  ?  ?? 
NH  P  es  P  P  es  P  P  P 
NJ  ?  ?  ?  7  ?  ?  ?  7? 
NM  P  P  P  es  es  P  P  =  c S (respite) 
Nv  P  P  P  es  P P P 
NY  P  P  P  es  P P P  Pc  S (respite+) 
oH  P  Cs  es  es  es P p
oR  P  P  P  Cs  Cs  P  P  P 
PA  P  P  es  es  es  es  P  Pc  S (attendant) 
RI  P  P  es  P  es  es  P 
Sc  P  Cs  Cs  Cs  P  P  P 
so  P  P  Cs  Cs  P  P  P 
VA  P  P  Cs  Cs  P  es  P  p
VI  ?  ?  ?  ?  ? ? ? ??
VT  P  P  P  Cs  es  es  P  PP (?) -
WA  ?  ?  ?  ?  ? ? ? ?
WI  ?  ?  ?  ? I ?!7  ?  ?? 
P  ~~  p 
es ! es ~ p  P  Cs 
TOT  1  9  12  24 I 21  11 1 7  6 
5  Voluntaw  Contributions  by Service  and  State 
Table 2 
WWregate  home  del.  in-home  in-home  adult day  transpt.  Iega(  ~= 
AK :  mxexa l  meal  medical  personal  care  ~  asst.  mgt. other 
AL I x  I x  1 x  x!  PI 
x 
AR ]  x  x  p(health promotion)

APzAj   x   1!   x..   x  Xx
1X  x  xx   xx   xx   )Xq(mhosmmec mAodific.a.t.i.on+)

x  x  Ix  _x  x x  x  elnm mool~ 
::  : I  Xj)(  !  ;Y..,f m,, 
CT  x X:  xix  x  x  x .X.IY!  ,, 
GFDDLEAC ~ Xxxx   )(  xxx  xxP	 I  xx  I  A.xYx  
  I  xA.vxx.      I  xxAx    xxPx 
   [Xx((hwlth)
 pmI mo/retreat.) I

IIHADI  xxx    xxx
  xXP jj)(  xx   xx.Y   II   xxAv
  II   Px-Av.    II  Pxw
  :X=(
esUM/recreation+)

IINL}  xx   lx,  x  xx~ ~  xx   x  xx  xP  xP   X(info.&assist.)
KKsY xx   Xx 1X  x I x lx  x xx xP xP
 
M x  x  x x x P

MA x x  x  x P P 
MD x  x  x  I nY  I  v  I  iw,-nean..n. promotion) 
ME x  x  P P IP  XxIXID ;  1  P  I  II


MMMoNI xxx   xxx   xP  xx  Yxn.. ~v-  II  AX 1X I1  A  11  x
 I  1  I 
x  X1X1X1  x~
Ms x x  x )x  x  x  P

MT x  x x x  I  x  x x x

NC ] x  x x x )x  x x  x

ND x  x

NNNNVMJH  xxxx     xxxx    PxPx    xxxxx  
 II PxPx 1X1XxxXx 11  X 1  XX.x. II PP  1II    x  IIlJ,Ilv-XqYD,!../=(1m(,\fn%!i,u.n-asA,-cv rlf.nl..nvw-.i- iw--al---lG.l.u) ,y-w/mu--uuAcc.?..a-+)u) 

NY  x
 x x x  x x  x  P

OH x  x  x 2(  x x 
OK x  x  P(?)

TSOSPRNDcAIR xxxxxx       ,xxx xx)(
     PxPP   xPxxPx 
   1 xxxXPf)   1 X1)(II   xvPxx   1  xP.xx-  
 I PPPPx
~

  
 x(?) 
Tx x  x  x  x ; x; xx   I

\lA  , ..  x xx
   x 
; ;  x 
x  x  x  x  x  X(LTC COOfd.) 
WA  x  xx   x x x  x  x  x  X(advoc.kounq
WI x  x x Xx ix
 x  x x P
x x

x x

w x  x  x x x x x

x  x  x x x

x=vduntafy~~ 
6
 The  AA%  will potentially  become  responsible  for developing  fee schedules,  for 
accounting  for and  tracking  funds,  and  for developing  default  policies.  Currently, 
AM  staff  may or may not  have  any experience  with these  activities. 
setting  off-
Within  their  current  cost sharing  and  voluntary  contribution  activities,  States  are  using

a variety  of fee  setting  practices.  After  determining  the  actual  value  of the  semice

provided,  a State,  ~  or service  provider  might  calculate  the  recipients  income,  and

use income  thresholds  and  fee schedules  when  determining  how much  a recipient  must

pay for a service.  States  with more  experience  with some  or all of these  activities

might  transition  into  Title  III cost sharing  more  easily or effectively.  In addition,  these

practices  may affect  how much  revenue  can be generated  horn  Title  III cost sharing.

Most  of the  States  that  conduct  cost sharing  programs  consider  personal  income  (29

States),  income  of a spouse  living in the  household  (27 States),  and  business  profits

and  interest  (25 States),  when  determining  if and  how much  a recipient  should  pay for

a sewice.  States  also consider  income  from  other  household  members  (14 States),

income  from  government  assistance  programs  (13 States),  and  assets  (5 States).  At

least  17 States  will deduct  certain  expenses  when  determining  a recipients  income.

The  most  commonly  deducted  expenses  are  medical  bills, including  prescription  costs.

Less  often  considered  are  expenses  such as housing,  utilities,  and  other  extraordinary

costs.  (See  Appendix  B for an example  of a form  used  to determine  recipient

income.)

Currentlyf  24 States  reported  that  they  use  an income  threshold  below  which  recipients

do not  have  to pay for the  service  they receive.  Thresholds  vary from  amual  incomes

determined  to be  at poverty,  going up to  150 percent  of poverty,  or they  might  be

determined  based  on monthly  income,  such as $800.00 a month  for a single household

member,  or $1500.00  a month  for two household  members.  In some  cases,  these

thresholds  are  determined  at the  local  level, and  vary from  AAA  to ~  or even

from  semice  provider  to service  provider  within  a State.

Some  States  use  sliding-scale  fee  schedules  to help  providers  determine  how much  a

recipient  must  pay for a service.  The  sliding scales  generally  address  the  fairness  issue

within  cost  sharing.  The  more  a recipient  earns  in income,  the  more  they  are

expected  to  pay  for a service.  Sliding scales  might  be a useful  tool when  marketing  a

cost share  program  - recipients  are  asked  to pay only what  they  can  afford.

Within  the  cost sharing  programs,  28 States  reported  that  sliding-scale  fee  schedules

are  used.  These  might  be  developed  at the  State  leve~ or left up  to the  M  or even

to the  local  provider  to develop.  (See  Appendix  B for an example  of the  sliding scale

used  in a cost sharing  program.)

Twenty-~o  States  also  use sliding-scale  fee  schedules  in the  collection  of volunta~

funds.  Although  recipients  of these  sexvices are  not  required  to pay for the  service,

7  the  fee  schedules  help  providers  and  recipients  determine  what  a recipients  fair 
voluntary  contribution  should  be.  States  already  using sliding scale  fee schedules  for 
their  voluntary  contribution  semices  might  be  better  prepared  to utilize  them  in cost 
sharing  activities. 
State  respondents  expressed  a variety  of opinions  regarding  the  potentialitieosf cost 
sharing  for  Th.le  III  funck  Opinions  ranged  from  great  support  for  the  id- to  great 
caution. 
Although  most  State  respondents  thought  the  cost sharing  would  not  affect  the  way 
they  provide  semices  to elderly  recipients,  about  one-half  of respondents  thought  that 
through  cost sharing,  they  could  expand  the  semices  provided  to recipients.  Sewices 
that  could  be expanded  include  transportation,  adult  day care,  respite  care,  and  other 
in-home  sewices.  Most  of the  respondents  were  unsure  of how much  they could 
expand  these  semices. 
Eipkiningcatdldg  tomc@?nB 
Some  respondents  expressed  that  the  successful  implementation  of Title  III cost 
sharing  will depend  on how well cost sharing  is explained  to recipients.  Of great 
concern  was how the  concept  of mandatory  cost sharing  will be  accepted  by recipients 
who are  used  to receiving  a senrice  for free.  Many  State  respondents  expressed  that  a 
personal  explanation  from  the  setice  provider  to the  recipient  about  the  need  for cost 
sharing  and  the  potential  benefits,  i.e. expansion  of services,  would  be  the  best 
approach.  This  approach  could  be supplemented  by the  use of letters  from  officials, 
flyers, announcements  at senior  centers,  and  the  use of the  media. 
Additional  ideas  about  successful  implementation  of cost sharing  Title  III funds  in 
diverse  State  environments  include  allowing  flexibility both  for and  within  States, 
phasing  in slowly a few semices  at a time,  and  using pilot  programs  in order  to test 
several  approaches. 
Tmgeting cfsakzs 
A few State  respondents  expressed  their  concern  that  cost sharing  of Title  III funds 
could  adversely  affect  current  targeting  strategies  and  availability  of sexvices to low-
income  elderly.  Respondents  were  concerned  that,  if allowed  to cost share,  providers 
might  reach  out  more  aggressively  to recipients  with the  best  potential  to pay a greater 
share  of the  setice.  No ideas  on how to counteract  this potential  effect  of cost 
sharing  were  offered. 
8
 Cost  sharing  with  Title  III  funds  raises  accountability  and  oversight  questions  for 
Stat=  AAA$  and  sentice  providers. 
Ihcume w@idon 
Nine  States  report  that  they  currently  verify the  income  of recipients  in their  cost 
sharing  programs  through  such methods  as reviewing  check  stubs.  Most  of the  cost 
share  programs  use self-declaration  by the  recipients.  Some  respondents  from  States 
where  these  methods  are  not  currently  in use expressed  concern  that  both  the 
declaration  and/or  provision  of proof  of income  will embarrass  or anger  recipients  to 
such an extent  that  they will drop  out  of programs  or discontinue  needed  semices. 
Furthermore,  some  State  respondents  also questioned  the  cost effectiveness  of 
verification  of income.  It is possible  that  the  time  and  resources  spent  on determining 
how much  a recipient  actually  earns  will surpass  the  amount  of cost shared  funds  that 
might  be  lost if self-declared  income  is erroneous. 
13iUng cdhx~  and targeting  issues 
Cost  sharing  with Title  III funds will require  billing and  collection  activities  on the  part

of States,  AAAs,  and  service  providers  that  might  not  currently  exist.  Currently,  in 26

States,  the  service  provider  both  bills the  recipient  and  collects  the  cost shared  funds.

In nine  States  it is the  AAA  that  bills and  collects  cost shared  funds.

In most  States,  for both  cost shared  funds  and  for voluntary  contributions,  the

collected  funds  are  re-spent  on the  same  service  they  are  collected  horn.  In most

cases,  because  the  funds  are  collected  by the  service  provider,  funds  stay within  that

sewice  and  are  thus  targeted  to recipients  with certain  needs.  This  is a fairly simple

way to control  the  use of cost shared  funds.  However,  in some  States,  where  the  AAA

or the  State  collects  funds,  the  collected  funds  might  be  used  to offset  expenses  for

other  setices.  This  allows more  options  for the  use of funds,  but  more  planning  and

tracking  of the  funds  might  be  required  as well.

Payment  default  ksucs 
Few  States  with  cost  sharing  programs  seen  to have  clear  or written  policies  and 
procedures  regardingpayment  default  by recipients.  At least  eight  States  leave  these

policies  up to individual  AAAs  and  semice  providers.  Other  States  expressed  to us

general  polici~  such  as sending  the  client  several  notices  before  services  are

terminate  or negotiating  with clients  for deferred  or different  payments.  Some

States  lean  toward  policies  which  require  termination  of semice  after  other  collection

methods  are  exhausted.  Other  States  strongly  avoid  terminating  services,  regardless  of

a recipients  lack  of payment.

9
 Acmunfing  &rues 
Sixteen  State  respondents  eqwessed  that  cost sharing  will change  the  way Title  III 
sewices  and  finds  are  accounted  for in their  State.  They  could  not  describe  what 
these  changes  will look  like without  more  information  on what  will be allowed  or 
required  in terms  of cost sharing,  Seventeen  respondents  also said  that  computer 
systems,  and  accounting  and  tracking  systems will have  to be  changed  and  updated  in 
order  to successfully  implement  Title  III cost sharing. 
10
 IMPLEMENTATION

States  currently  operate  in widely diverse  environments  regarding  current  voluntary 
contribution  practices  and  cost shared  services  and  programs.  Within  States,  AAAs 
and  service  providers  might  vary greatly  with  their  practices. 
If the  Congress  enacts  legislation  permitting  the  use  of cost sharing  for Title  III funds, 
the  AoA  will need  to consider  practical  aspects  of several  issues.  These  include: 
Direction 
The  mandates  and/or  direction  AoA  will give to the  States  concerning  kinds  of 
semices  cost  shared;  the  setting  of fees,  including  the  calculation  of recipient 
income,  income  thresholds  and  sliding-scale  fee  schedules;  and  the  billing, 
collection,  and  targeting  of cost shared  funds. 
oversight 
The  development  of oversight  and  accounting  activities  which  will be  necessary 
on the  part  of Ao~  the  States,  AAAs,  and  sewice  providers  in regard  to cost 
sharing  Title  111funds.  This  includes  policies  on income  verification,  and 
payment  default. 
Technical  Assistance 
The  training  and  technical  assistance  which will be  available  to States,  AAAs, 
and  service  providers  in regard  to implementing  Title  III cost  sharing.  Some 
States  will need  more  help  than  others. 
AaAk  CI)nunerm 
The  AoA  provided  comments  about  this report;  they  can be  found  in Appendix  C. 
The  AoA  states  that  the  information  in the  report  has  provided  them  with  the 
necessary  background  information  required  to assess  cost  sharing  language  in 
reauthorization  bills proposed  by the  majority  in both  the  House  and  the  Senate.  The 
AoA  also  anticipates  that  the  survey  data  will provide  baseline  information  to develop 
program  policy  and  technical  assistance  for State  agencies  administering  programs 
under  the  Older  Americans  Act. 
11
 APPENDIX  A 
Surveys and  Responses 
A-1  STATE  53 Returned 
PLACE AN XNEXT TO OPTIONS THAT DESCRIBE YOUR STATE. 
1. Is there any cost sharing for any seMcea provided to elderly recipients in your State? 
YES  36  ANSWER QUESTIONS 2,3, and 4 ONLY. 
NO  17  ANSWER QUESTION 5 ONLY. 
2. Please check the option that applies in your State: 
All AAAsin*  Sti&mmt-t*13  . 
Some AAAs  must cast share ~. 
PLEASE SEND A LIST OF WHICH 
AMs  MUST COST SHARE. 
*q-to 
costshareornfJ~t. 
IF KNOWN, PLEASE SEND A
LIST OF WHICH AAAs CHOOSE TO COST SHARE. 
3.	 Does  the State conduct any cost sharing separate horn AAAs? 
NO 
YES  22  (PLEAsE  EXPLAIN BELOW.  USE SEPARATE PAGE IF 
NKESSARY.) 
cost share  through  Medicaid  waiver, social  Security  Block Grants.

Sbte  is single PSA

statehas cat sharing  both  separate  from and through AAAs.

A-2
 4.	 Listed  below are actions State Units on Aging might take when allowing or requiring 
AAAs or heal  providers to cost share.  Please indicate whether your State Unit on 
-g  h=  taken any of the following actions: 
Action  NO YEs 
~ Provide guidance to AA4s/LPs to help them  develop  fee schedules  and  I  I 14 
procedures. 
Review AAAsJLPsproposed  fee schedules  and procedures.  12 
Approve AAAs/LPs proposed fee sehedulea  and procedures.  7 
Develop  fee schedules  and procedures  to be implemented  by AAA/LP.  18 
Develop  fee schedules  and prowdures  used by State.  16 
Other  (PLEASE  SPECIFY) 
5.	 Does  your State  have any plans to require  or allow cost sharing  for seMees  provided  to 
elderly  people through  the  State,  AAAs or other  local providers? 
NO 
YES5  DESCRIBE  BELOW  CURRENT  PLANS  FOR  COST  SHARING  IN 
YOUR  STATE.  USE  A SEPARATE  PAGE  IF NECESSARY. 
A-3
 MAKN SURVEY  SECIION  I - CURRENT  COST  SHARING  PRACIICES 
1.  Listed below  are various  seMces  that  might be offered  to elderly  people  through  SUAS, A&k, 
and LPs.  Please  consider  the  types of seMces  listed below. If the seMce  is not  provided  in your State 
at U  cheek  N/A column.  If the seMce  is provided  in your State,  but  there  is no east sharing  for that 
seMce,  check  the  NO column.  If the seMce  is povided  in your State,  and there  is -t  bring  for 
the seMce,  check  the YES  column.  Please  check only one option  in the  first three  columns. 
If the answer  is YES, go to the  next three  columns  and write  in the SPENT  column  how much 
money  (excluding  Title  III funds)  in FY  1994 was spent  on the  seMce.  In the  COLLCITl  column 
write how much  money was collected  for that seMce  from cost sharing  in FY  1994.  If you only have 
money  amounts  for another  year, please write  those,  but  indicate  to the  right of the table what year 
the  amounts  are for.  If you dont know how much money was spent  or collected  in any year, check 
the  DK column.  If you only have total  amounts  for all setiees,  please  write  those  at the bottom  of 
the table. 
$$$  S$$ 
TYPE  OF  SERVICE  NIA  NO  YES  SPENT  COLLCTD  DK 
I 
Congregate  Meal  1  28  1  11 
Homedelivered  Meal  2  19  9  8 
In-home  SeMces  (Medial  - skilled  8  10  12  9 
nursing,  physical therapy,  etc.) 
In-home  Setiees  (Penonal  -housewdq  o  5  24  14 
errands,  etc.) 
Adult  Day Care  1  8  21  I  ] 14 
Transportation  1  18  11 
Legal A&stance  2  26  1 
Case  Management  1  19  7 
Othec  (PLEASE  SPECIIW)  1  5  5  1 
To@: 
SEND ANY COST REPORTS  OR  OTHER  DOCUMENTATION  SENT  TO  YOU  BY W/Lps 
WHICH  EXPLAXN THE  ABOVE  LISTED  SS&  AND  ANY  OTHER  COST  REPORTS 
FORMULATED  BY THE  STATE  FOR  ACCOUNTING  FOR  AND  TIUCKING  THE  COST 
SHARED  FUNDS  DESCRIBED  ABOVE 
A-4
 2.  The  table  below describes  different  ways cost shared  fees might be determined  in your State, either 
by the State, AAA or LP.  Indicate YES or NO if the option  applies  in your State.  We are aware 
that  all options  might apply in your State,  due  to vaxying AAA/LP  practi~.  If unknon,  check the 
DK dllmrl. 
OPTION 
No  YES  DK
Everyone  pays the same set fee based on seMce  provided,  regardl- of 
different  incoma.  *MD, RI, VT  26  3*  1 
~ruing
some  people  pay the same set fee bti  on seMw  pro~d~,  after  22 6*  1
an income  threshold.  KS, MO,  NY, RI, VT, WY 
winag  
People  pay different  fees for different  sefi~,  b&  on in~me,  1* 28 
sliding-scale fee sch~ule.*MA  **CA  ~  2** 
Othec  (PLEAsE  SPECIFY) 
 DC - Based on setice  cost, people  pay different  fees for the setice.  3  1*  1 
A 
I 
IF AV-LE,  PROVIDE  FEE SCHEDUL=,  AND SLIDING SCALE TABLEs. 
3.  Considering  most seMces  which are cost shared  in your State,  does  the State,  any AAAs  or LPs 
use an income ceiling above which people are not eligible for some semices? 
DK ~ 
NO  18 
~  10  IF YES, EXPLAIN BELOW FOR WHICH SERVICES AND/OR WHICH ~/Lps 
USE AN INCOME CEILING.  IF AVAILABLE, PROVIDE  DOCUMENTA~ON  OF 
CEILING AMOUNTS. 
EXPM: 
DC, GA  MA  MO, m  PA  U  SD, VT, WA 
*me  S~*  ~  monw  ~cmnes which range  from $7SO.OOto $1700 monthly  for an individual.  One 
State  uses 3W percent  of poverty,  another  uses 300 percent  of SS1. 
A-5
 4,  Listed  below are various sources  of income.  For moat serv-kxs that  are cost shared,  indicate  by 
checking  YES Or NO whether  the  State, 4  or LP considers  each source  of income  when 
determining a clients cost shared fee.  If the answer is YES, check  the  VER column,  if this income 
is documented  and verified  by such methods  as reviewing pay stubs, etc. 
SOURCES  OF  INCOME  NO  YES  VER  DK 
Personal  (wages, salaries,  retirement/pensions,  Social Security, income  1  29  9*  1 
from insurance,  etc.)  *CT,DC, HI, Q  ~  OH,  PA  RI, VT 
Business and investment (profits, interest  dividends, rent, etc.)  13  125  \7*  3 
Income  of spouse  living in household.  ~,  DC, HI, II+ ME, OH,  2  27  9*  1 
PA  RI, VT 
Income of household members other than spouse.~  ME, PA  RI,  14  14  5*  3 
VT 
Income  from government  assistance  programs  (Food  Stamps,  AFDC,  15  13  3*  1 
etc.)* DC, CT, OH 

Assets  (home,  vehicles,  etc.)*CX,  MD,  MN, NM, SD  *CI  23  5*  1**  1 
Othe~  (PLEASE  SPECIIW)  o  0 0 
IF AVAILAB~  PROVIDE  COPIES  OF  FORMS  USED  K) DJHHUINE  INCOME 
5.  Considering  most cost shared  seMces  in your State,  does  the State  or any AAA/LP  use an income 
threshold  below which people  do not  have to pay for any serviee? 
DK 2  CA MN 
NO  4  DC, KS, QNH 
YES  24  IF YES, EXPLAIN BELOW FOR WHICH SERVICES AND/OR WHICH 
A%4#LPs  HAVE AN INCOME THRESHOLD.  IF AVAILABLE  INCLUDE 
DOCUMHWATION  OF THRESHOLD  AMOUNTS. 
EXPLAIIL

Poverty or below - CI, II+ OI& PA  SC, SD,

12S% of Poverty or below -GA

150% of Poverty or below - NY

Approx. $8000.00 or less annual income for one person - KY, VA

Approx. S800.(K)or less monthly income for one person - MO, WA

Those with Medicaid eligibility or incomes less than - MA

Determined  at local level - MD, VT

A-6
 6. Does  the State,  or any AAAs  or LPs deduct any client expenses  (e.g. housing,  medical, loans) from 
clients income when  determining  fee levels for services? 
DK  4  CA  CT, NM, NV 
NO  10  DC,  GA  IL  KS, L%  N@  MD, NH, WA 
YEs  17  IF YES,  EXPLAIN  BELOW  WHAT  EXPENSES  ARE  DEDUCTED  WHEN

DETERMINING  FEE  LEVELS.  IF AVAILABLE  PROVIDE  FORMS  OR  OTHER

DOCUMENTATION  TO  ILLUSTRATE.

EXPLAIN:

MEDICAL  - HI, ID, IN, KY, MO,  OH,  OR,  PA  SC, VA  VT, WY

HOUSING  - NY, VT, w

ENERGY  - SC

NON-EMPLOYMENT  INCOME  (such as IRS deductions)- ID

DEPENDENT  CARE  - VT

OTHER  - (extraordinary  situations  that  affect income,  situations  that  are determined  on case by case

basis) - KY, ~  SC, VT

UNKNOWN  - RI, SD

7.  Below are various  actions  SUAS might  take when collecting  cost shared  fbnds or aIlowing A&%  or 
LPs  to collect  cmt  shared  funds.  Indicate  by checking  YES  or NO if your State  has taken  any of the 
following actions.  (CHECK  ALL THAT  APPLY.) 
ACIION  NO  YES  DK 
State  bills client  and collects  mat  shared  funds.  *SD, RI  +~  27  2*  1+ 
12810 
AAA  bills client  and State  collects cost shared  funds. +CT  11+ 
AAA  bills client  and collects  cost shared  funds.*G~  IN, KY, N@  NY, OH,  20  9*  1+ 
OR. PA  VA  +CI 
LP bills client  and State  collects cost shared  funds.  *SD  +~  27  1*  1+ 
LP bills client  and CQllects cost shared  fimds.*SD,  OH  +C/&  VA  2*  26  2+ 
4* 
Othec  (PLEASE  SPE~)    DC  -client  pays contractor 
PA -clientsends receipts  to AAA  and is reimbursed 
MO  - state  deducts  co-pay for providers  reimbursement 
HI- client  pays contractor  and is reimbursed  by LP 
IF AVAILAB~  PROVIDE  EXAMPLES  OF  FORMS  USED  TO  BILL  CLIENTS,  AND  OTHER 
BILLING  PROCEDURES  OR  POLICIES. 
A-7
 8.  Below are listed various  seMces  which might be cost shared.  The  columns  to the right give 
different  times when  payments  on cost shared  funds might be collected.  The  times are ONCE  A 
MONTH  (MON);  md  AT THE TfMEOF THE SERVICE (SER).  We are aware that these times 
might vary by individual  AAA/LP  practice.  Check  the VARI=  (VAR)  column  if this is the case.  If 
there  is some other  time when  payments  are collected  in your State,  check  the OTHER  (OTH) 
column  and indicate  to the right of the table what  that  time is.  If unknow,  check  the  DK column.  If 
the senice  is not  cost shared  or is not  provided  in your State,  check  the  N/A column. 
TYPE  OF SERVICE 
MON  SER  VAR  OTH  DK  N/
A 
congregate  Meal 
1  2  1  ()  1  ~J

Assist with bathing/

10  1  9  (-j  1  7

dressing  in the  home 
Respite Care 
6  3  7  1  1  lo 
Home-health  seMces  (skilled  nursing,  physical 
6  1 6 0 2  ~~ 
therapy,  etc.) 
Emergency  reqmnse/aleti 
1 1 5 0 3  18 
Friendly  dsfiits 
1  0  1 () 2  23 
Light housework 
11  1  10  0  2  4 
Errands/shopping 
10  1  6  0  2  9 
Handyman/minor home  repair 
33  60  11 J 
Transportation 
23  60  31  3 
Legal assistance 
12  2  0  12  ~ 
Adult  Day Care 
10  1  9  ()  3  6 
&  management 
3  0  4  0  11 (J 
counseling 
2  0  1  (,) 2  22 
Other  (PLEAsE  SPE~*MA-bW  for entire  program  3 
2 + 
MO-RN  visitand ~  personal,  KS-senior  care act 
+NY-respite  and ancillary, PA-partial  hospitalization 
A-8
 9.	 Please explain general policies and procedures used by the State, and if known, by most AWWILPS 
in the State  when  ciients default  on cost sharing  bills.  ATTACH ANY AVAXLABLE 
DOCUMENTATION  EXPLAINING  POLICIES  AND  PROCEDURES. 
Policy developed  by AAA/LP  - G4  HI, KY, NM, OR,  PA  VA  VT

Give client several  noticedchances  to pay before  sernce  termination-ID,  IL  OH,  PA  SC, W

Will try to work out with clients  on case by case basis -HI, ME,  OR,  PA  SC

Generally  will not  terminate  seMces  -NH, NV, OR,  SC, VT, WY

Generally  will terminate  seMces  after  other  collection  methods  are exhausted  -ID, IL, IN, KS, ~

ME,  NY, OH,  PA  SD, VA

Other  - DC (seMce  is provided  only on receipt  of payment  for a voucher.)

Unknown  - Al& CA  MD,  MN, MO

10.  Listed  below  are some  options  regarding  how cost shared  funds  might be spent  after  they are 
collected.  Indicate  by checking  NO or YES  if this option  applies  in your  State.  We are aware that 
more  than  one  option  might apply in your State  due  to varying AAA/LP  practice.  Check  all options 
that  apply. 
OPTIONS  NO  YES  DK 
2*  ~  3 
Collected  funds  are spent  only on the same  type of service.*KY,  NY 
Collected  funds  are used to of&et  administrative  rests  at State/local  18  7*  4 
level.~  @  ~  NV, ~  VA  VT 
CQlkted  funds  are used to oftket expenses  for other  seMces.*MO,  ~  16  7*  6 
NY, 0~  PA  ~  VA 
COllected fimds are used to offset  expe~  m other  State/local  20  5*  4 
programt*MO,  NY, ON  RI, VA 

Other  (PLEASE  SPECIFY)  KY -unknowm  VA  -unexpended  balances  2* 
must  be spent  on critical care needs. 
A-9
 11.  Does your State keep  track of, or have any records  or reports  indicating  the  administrative  costs 
incurred  horn cost sharing  practices? 
DK  3 
NO  26 
YES2  (PLEASE  EXPLAIN,  AND  ATTACH  ANY PERTINENT 
DOCUMENTATION) 
KS - difficult  to calculate,  but  administrative  casts  to not  exceed collected  amounts. 
VA - each  AAA  reports  cost of administering  fee for seMce  program. 
A-10
 SECTION  II - CURRENT  VOLUNTARY  CONTRIBUTION  PRACIX~

12.  Below is a table  that  lists various  seMcea  that  could be provided  in whole  or in part with Title  III 
funds.  As with the  first table, check  the N/A column  if the seMce  is not  provided  in your State  at all. 
Check  the  NO column  if the seMce  is provided  but voluntary  contributions  are not collected at all fol 
the service.  Check  the YES column  if the seMce  is provided  and voluntary  contributions  are 
collected.  Check  only one  option  for each seMce. 
If the  answer  is YES,  indicate  how much of Title  III money was spent  on that  seMce  in FY  1994 and 
how much was collected  in voluntary  contributions.  If you have figures for another  year, use those 
figures, but  indicate  what year to the right of the  table.  If figures are unknown,  check the  DK 
column.  If only total  amounts  are know  write  those  in the last row. 
$$$  $$$ 
TYPE  OF  SERVICE  N/A  NO  YES  SPENT  COLLCTD  DK 
Congregate  Meal  o  0  49 
Homedelivered  Meal  o  0  49 
In-home  SeMce  (Medical  - skilled  16  9  22 
nursing,  physical therapy,  etc.) 
In-home  SeMces  (Personal  -housework  1  3  43 
errands,  etc.) 
Adult  Day Care  5  4  37 
Transportation  o  1  48 
Legal Assistance  o  7  41 
Case Management  6  17  22 
Othec  (PLEASE  SPECIFW)  o  2  17 
Totalx 
SEND  ANY  COST  REPORIS  OR  OTHER  DOCUMENTATION  SENT  TO  YOU  BY f%%%~ps 
WHICH  EXPLAIN  THE  ABOVE  LISTED  OTHER  COST  REPORTS 
$$$S,  AND  ANY 
FORMULATED  BY THE  STATE  FOR  Accounting  FOR  AND  TRACKING  VOLUNTARY 
COLLECTEFUDNDS. 
A-n  13.  Does  the State  or any AAAWPS use any fee scheduledincome  requirements  to determin 
suggested  contribution  amounts? 
DK  4 
NO  23 
YEs  22  (EXPLAIN  BRIEFLY  BELOW  AND  ATTACH  FEE  SCHEDULES,  ETC.) 
AAAs/LPs  required  to develop  schedules- PA  SC, TN, WV

AAAs/LPs  allowed but  not required  to develop  fee schedules  -CA  GA  NY

A4A/LP  vary in establishing  fee schedules- AZ,  CA  CT, MN, NH, SC, TN, ~  VA

State  has recommended  fee schedule  for A&VLP  use -NC

Other  - NM (AAAs  post cost of meal at mealsite),  RI  (nutrition  project  m.msels  for meals),

(home  health  agencies  use fee schedules.)

Unknown  - DE,  ID, MI, SD

14.  Listed  below are actions  SUAS might take when  collecting  voluntary  contributions  and/o 
or requiring  AAAs/LPs  to ccdlect voluntary  contributions.  Please  indicate  whether  your SUA 
taken  any of the  following actions: 
Action  NO  YES

20*  2g

Provide  guidance  to AAAs/LPs  to help  them  develop  fee schedules  and 
procedures.*~m~DC,~G&m  ID, II+ IN, NL%MD,  MN,

Review  AAAa/LPs  proposed  fee schedules  and procedures.   &  AR,  CO,  22*
 24 
ZG~~m,  ~w,  W~~,  ~~,  ~,~,  W,  O~SC,

VT, WI, WY

Approve  AAAs/LPs  proposed  fee schedules  and procedures.~  DC,  35  10*

DE,  MS, NV, NY, OR  PA  RI, SD

Develop  fee schedules  and procedures  to be implemented  by AAA/LP.  35  12*


CT, GA  ID, LA  NCj ND, NV, OR, PA  RI, SC, SD

Develop fke schedules and procedures used by State.  CT,RI, SD, WI  42  4* 
Other (PLEASE SPECIFY)  o 
A-12
 15.  Below are actions a State, AAA  or LP might take when seeking  volunta~  contributions  from 
clients for seMces.  Check  YES or NO if any of t-he following actions  &cur  in y&r  State.  If 
unknow$  check  the DK column. 
ACIION  NO  YES  DK 
Give client  written  information  on suggested  contribution  amounta.*IN,  WI  2*  44  2+ 
+%  WA 
Give client  envelopes  to submit  contniutions.~  ID, MS, WY  + WA  4*  42  1+ 
Set out  a locked  box in which clients  may contribute. *NH  +VT,  WA  1*  45  2+ 
Send  client  monthly  statement  with suggested  contribution  amount.%  20  23*  4+ 
CO, ~,  DC,  DE,  HI, IA ,KS, ~  MI, MN, MO, ND, NH, NV, OR,  PA 
SC, SD, ~  VA  WV, WY  +KY,  NJ, VT, WA 
Negotiate  amount  of contribution  with client or family member.~  AZ,  24  19*  5+ 
CO, cr,  DC, HI, u  ME,  MI, MS, ND, NH, NM, NV, pz% ~,  SC, SD, 
TX  +MT,  OR,  VA  VT, WA 
Ask for contributions  from family members.- DC, DE  %  HI, KY, @  19  23*  5+ 
MD,  MI, MO,  MS, MT, ND, NJ, NM, NV, OR,  PA  RI, SD, ~  VT, WV. 
+AR,  h@  NH, v~  WA. 
Othen  (PLEASE  SPECIIV)  *MS -promote  contributions  using written  3* 
and verbal  methods,  SD -use a monthly  ticketipunch  card system  WI -give 
client  information  on service cost per unit. 
PROVIDE  EXAMPLES OF FORMS, STATEMENTS,  AND/OR ENVELOPES  USED TO 
COLLECT FUNDS. 
A-13
 16.  Listed  below  are some  options  regarding  how voluntarily  contributed  funds  might be spent  after 
they are collected.  Indicate  by checking  NO or YES  if this option  applies  in your State.  We are 
aware that  more  than  one  option  might apply in your State  due  to va@.-ng  AAA/LP practice.  Check
all options  that  apply.  -
OPTIONS  NO  YES  DK 
Collected  funds  are spent  only on the seMce  they are collected  frorn.~  4*  39  4 
KY, OR,  SC 
Collected  funds are used  to offket administrative  costs at State/local  level.  35  8*  3 
*GA  ~  ME,  NV, RI, V&  VT, WV 
Collected  funds  are used to offset  expenses  for other  setices.   CO, G~  26  15*  5 
~~=,~ME,~,NH,OR,P~N,SC,V~W 
Collected  funds are used to offset  expenses  in other  State/local  programs.  39  2*  5 
*KY. LA 
Othec  (PLEASE  SPECIIW)  *KS -collected  funds must be used within  1* 
same title 
A-14
 17.  Below are listed various  seMces  which might have voluntary  contributions.  The columns  to the 
right give different times when voluntarily contributed payments might be collected.  The times are 
ONCE A MONTH (MON); and AT THE TIME OF THE SERVICE (SER).  We are aware that 
these times might vary by individual AAA/LP practice.  Check the VARIES (VAR) column if this is 
the case.  If there is some other time when payments are collected in your State, check the OTHER 
(OTH)  column  and indicate  to the  right of the  table what  that  time is.  If unknown,  check  the  DK 
column.  If the seMce  has no voluntary  contributions  or is not provided  in your State,  check  the N/A 
column. 
TYPE  OF  SERVICE  MON  SER  VAR  OTH  DK  N/A 
Home  Delivered  Meal  5  7  35  1  1  0 
Congregate Meal  1  31  16  0  1  0 
Assist with bathing/  6  2  28  1  1  9 
dressing in the home 
Respite Care  7  2  26  1  1  10 
Home-health seMces (skilled nursing, physical  2  1  20  1  2  21 
therapy, etc.) 
Emergency responsdalert  1  1  14  1  5  24 
Friendly  callshisits  o  2  17 1  3  21 
Light  housework  6  4  28  1  1  5 
Errands/shopping  4  3  27  1  3  8 
Handyman/minor  home  repair  o  5  27 1  1  11 
Transportation  1  22  22  1  1  0 
Legal  assistance  1  8  2s  1  4  7 
Adult  Day Care  6  3  26  1  1  10 
Case management  2  2  17  1  2  22 
Counseling  o  1  15 1  3  2s 
Other  (PLEASE  SPECIFY)   HI - escx.xt, MA-health  o  3*  o 0 0
promotio~  VAden@  health  promotion,  emergency,

financial  consulting,  info and referral.

A-15
 SECfION  III - IMPLEMENTATION  OF TITLE  III COST  SHARING 
18.  Listed  below are some potential  changedeffects  that  might happen  in your State  if cost sharing 
for certain  lltle  III funds is implemented.  Check  the NO column  if you believe  the change  will not 
happen  in your State.  Check  the YES column  if you think  this change  might happen  in your State 
AND  EXPLAIN  BELOW  HOW  YOU  THINK  THAT  CHANGE  MIGHT  OCCUR.  Check  the DK 
column  if you do not  know if this change  will happen  in your State. 
POTENTIAL  CHANGE  NO  YES  DK

Cost sharing  of Title  III funds will change  the way setices  are provided  in  24  14*  11

the  State.* AZ,  CO, HI, KY, @  ~  ~  MN, NC, NM, RI, TN, ~  WI

Cost sharing  of TMe XIIfunds will change  the way funds are allocated  to  27  1*  19

MAs.KY

Cost sharing  of Title  III funds will change  the way funds are allocated  to  21  4*  24

LPs.*HI,  KY, NM, RI

Coat sharing  of Title  III funds will change  the way funds are accounted  for  17  16*  16

by the State/&U4/LP.*AR,  ~,  GA  KS, KY, w  MI, MS, ND, NY, PA

RI, TN, VT, WI, w

Other  (PLEASE  SPECIFY)  2  1  2


EXPLAIN  YES  ANSWERS: 
18D  ND  -t  sharing  mandates  may decrease  the  number  of higher  income  people  if the  fee scale 
requires  that  significant  increases  be made. 
180TH: 
AR  -client ccmtriiutions  are not  reported  in detail  to the state  at present.  If cost sharing  were 
implement@  those  funds would  have to be reported  diHerently. 
CA-cost  sharing  clients would create  additional  administrative  costs. 
MS-will need  new procedures  for dealing with large amounts  of funds. Will need  closer security or 
new ways of dealing  with funds. 
ND-cost  sharing  could  affect the  type of person  receiving  the seMce. 
A-16
 19.  Listed below are various servi=  that might be funded  wholly or in part with Title  III funds.  If 
you believe  that  this seMce  can be expanded  and provided  to more  recipients  by cost sharing  the Title 
III funds spent  on this setice,  check  the YES column.  Estimate  to the right of the YES column  a 
percentage  on how much this seMce  might be expanded  through  coat sharing.  If the seMce  cannot 
be expanded  through  cost sharing,  check the  NO column.  If you do not  know, check  the  DK column. 
TYPE OF SERVICE  DK  NO  YES  PERCENT 
Home  Delivered  Meal  16 12  21 
Clmgregate  Meal  17 17  16 
Assist with bathing/  21 6  21 
dressing  in the  home 
Respite  Care  23 5  21 
Home-health  seMces  (skilled  nursing,  physical  24 7  14 
therapy,  etc.) 
Emergency  response/alert  23 7  12 
Friendly  calldvisits  22 21  5 
Light  housework  19 6  24 
Errands/shopping  19 9  21 
Handyman/minor  home  repair  22 6  21 
Transportation  18 6  26 
Legal  assistance  23 6  21 
Adult  Day Care  19 5  24 
Case management  23 13  11 
Counseling  22 10  9 
Other  (PLEASE  SPECIIY)  2 
A-17
 20.	 What  might be some of the reactions of recipients of Title III funded seMces to the 
implementation of mandatoV cost sharing for certain setices? 
Recipients  will drop  out  of programs:  21 -AZ,  CI,  DC, DE, GA  GM, HI, IA  KY, LA  MA MO, 
MT, NH, NY, OL  OR, SC, SD, VT, WY 
Recipients  will say they cannot  afford seMces:  15 -AZ, CT, DC, IL, KY, MA  ND, NH, NY, PA  SC, 
mvT,wAw 
Recipients  will feel resentment/embarrassment  about  revealing  income:  12 -GA  H+ MA  ME,  ND, 
NY, OK  SC, SD, TX  WA  WI 
Recipients  will understand/acxxpt  necessity  12 -~,  DE,  GA  IA  ME,  NH, NY, SC, SD, TX  VT, 
21.	 What  are some ways that  cost sharing  for Title  III funds might beat be announced  and explained 
to recipients? 
Public  noticedmass  media/hearings:  12-Dg  GM,  HI, KY, L%  M  h@  MT, ND,  NY, p~  ~

Involve  elected  officials: 3-&  KY, LA

Have seMce  provider  inform  recipient  in person:  12 -AZ, DC, DE,  GM,  II+ KY, ME, ND,  OR,  PA

WA  WY 
Send  letters  horn  AoA  and/or  State  Agencies:  5- GM,  IL, KY, ~  WA

Distribute  flyerdother  information  at senior  centers:  4 -AZ,  HI, I+@ PA

Explain  need  for cost sharing/how  cost sharing  will help  maintain  or expand  seMcea:  15 -~,  DC, GA

~~U~O~O~SC,SD,~VT,W~W

Other  suggestions

Use pilot  programs  to phase  in cost sharing.

Involve  recipients  in planninghmplernentation.

Give clients  plenty  of notice.

Make  sure  there  is policy that  no one  will be refused  seMce  for inability  to pay.

Do not  use mass media.

A-18
 22.  What  resources  (e.g. staff, systems, etc.) does your State  anticipate  it will take  to impleme 
sharing  for Title  III funds? 
Staff time at State, M  and/or LP level: 12- AZ, ~,  DC, GA  HI, KY, ME, NY, OK  OR 
Update  computer/accounting/tracking  systems:  17 -Cf, DC, GA  GM,  KY, ~  ME,  MA  MT 
ND, NY, w  VT, WA  WI, WV 
Develop  new policies and procedures:  6 -HI, KY, ME,  MS, NY, VT 
Training  time:  10 -GA  HI, L  KY, MS, NC, NY, OEL VT, WI 
Other  costs: 
Materials 
Travel 
Printing 
Audita 
23.  Please comment below on any other implications of cost sharing of Title 111funds. 
State supports  cost sharing  5- DE,  GA  ME,  SC, SD 
Coneem that east sharing will aikct  targeting and availability of aeMees to low-income elder 
7-cr,  Dc,  &ND,  NY, vT,  w 
Other  comments: 
Would  like to eust share  nutrition  semiees. 
State already reeeives substantial amounts in voluntary eontnbution  - cannot see how cost sh 
bring in more. 
Cost sharing  constitutes  a major change in philosophy -should be considered carefully. 
Carefully eonskier the cost effeetivenesa  of - sharing  especially  if recipients  must veri@ in 
A-19
 APPENDIX  B 
Examples  of State  Forms  for Determining  Recipient  Income  and Sliding Fee  Seal= 
B-1  SAME  DATE 
ADDRESS  WORKER 
1.	 Monthly income (less federal, state, local uxcs  includbg  FICA) 
Social Security/RR Reuremem 
PensiOdAnnuities 
Net wages 
Imeres@ividends 
Workers, Unemploy., and  or Disability Compensation 
Other Income 
TOTAL 
u.	 Exclusions 
A.  Medical exclusions that exceed 7.5?4ofincomemaybe  deducted: 
1. Acti  monrhly inc~me  x 7.5% = 
2,	 Monthly medical expenses 
Sub&act 1 fkom 2 
B.  Housing excluions  that exceed 30%oof income may be deducted: 
1. Actuid monthly income  X 30%O= 
2.	 .Monrhly housing expenses 
Subtract l from 2 
Add Medical exchsions  andhousingexclusions 
Subtract exclusions from acrual monthly income to obtaur adjusted income snd detenm.ne bracket for sliding fee 
scale. 
SLIDING FEE SCALE 
Adjusted income 
- -., ..  1 P-ON  2 PERSONS  Cost per hour 
<1000  <13(3(3  no chge 
1001-1050  1301-1350  1.50 
1051-1100  1351-1400  2.00

1101-1150  1401-1450  ~.jo

1151-1200  1451-1500  3.00

1201-1250  1501.1550  3.50

1251-1300  1551-1600  4.00

1301-1350  1601-1650  4.50

1351-1400  1651-1700  5,00

;	
1401 = 1450  1701-1750  5.50

1451-1500  1751-1800  6.00

1501-1550  1801-1850  6.50

1551-,1600  1851-1900  7.00

1601-1650  1901-1950  7,50

. . 
1651.1700  1951-2000  8.00

1701-1750  2001-2050  8.50

---- 1751-,~fOQ  - 2051-3000  .. . 9.00 - ..-

,; . .. 
1801- 18S0  3001-3050  9.50

18S1 -,1900  3051-4000  10.00 
,,, 
Inwme  excccd&  rhcse levels, a flatrateof $10.50 per hour will be charged. 
~,,- Foreachadditio&dlegaldependent for Inhxnal Revenue Service purposes, deduct $200 from monthly adjusted 
,,  &me  and use 2 person scale to determine appropriate brscketon sliding fee scale. 
.  ly,  Your fee fir  Personal care  Home Support  Attendant Can 
,,  ..  Home Modi&adon  Opuons II  service has been determined to be 
,. 
.s    per hour of setvice. 
;1 
,, 
Client signature 
B-2
 a-q 
for  the  Eiderly  Prcgram 
Expanded  ln  -Home  SerVICes 
I 
cLI~T  COST s~ING 
HREsH0LDsl~9: 
~
Effective  January  1, 
. 
A.  Monthly  Income  Thresholds 
$946  per  month 
INDIVIDU-  
co~LE...e  =  S1,264  per  month 
B.  Housing  Adjus-ent  Thresholds  adjustment  f  averago  monthly 
1)  To  be  eligibzl=  ~;s~  ~;~;g  than  the  following: 
housing  expenses 
INDIVIDUM  =  $378 
CO~LE  . . . .  =  $506 
not  be  more  than 
of  the  housing  adustment  can 
2)  The  amount 
the  following  maximum  amounts: 
INDIVIDUW  =  $189  per  month 
=  $253  per  month 
COUPLE.  000 
C.  Cost  Share  Rate  Schedule  1 
COUPLE 
T 
lNDIVIDUM 
Fe. 
Adjusted 
Fee  Rate 
J@jUSte~  Income 
Rate 
Income 
.  Ot 
$0 
*  o% 
$0    $1 to  $44     ~:: 
5% 
$1  to  $33    $45  to  $89 
10%  158 
$34  to  $66  $goto  S133 
15 4  2ot
$67  to  S1OO  $134to  $177 
20 8  .258 
$101  to  S133 
$134to  $166      ; %  :::::  :~~      ::: 
$167t0  $*99  $267  tO  $311 
3 58  408 
$200to  $232  $312to  S355 
4 O*  45$ 
$233to  S26~  $356to  $399 
4 58 
$266t0  S299  $400  to  S444      ; ;; 
S$330303   ttoo   $$333625       ;;:  s$444859 t0 tO  sS45883 2  6 0% 
608  658 
$366  to  S3- $533  to  S577 
658  7 Ot 
$399  to  S431  70%  $578t0  $621  .  .7 5* 
$432  to  S46~ 
808 
S$449696 - to  $S453918       :%  x$:7=1 1  to  :S::7:5 4    85% 
85%  908 
S532to  S564  $755to  S799 
908 
$565  to  $597  ;:: 
95% 
$598  to  S631  zzZ%ans~;~3*  1 
100? 
More  than  S631* 
b 
  Or  eligible  for  Medicaid. 
OFA NO.  282  (revised  12/94) 
B-3  APPENDIX  C 
AoAs Comments 
c-1  TO.  Inspector OesmraI 
FROM.  Assistant  Secretary  for Aging 
SUBJECE01(3 Draft  Report	 Cost Sharing  Under  the  Older  Americans Act 
&l-65  - q~ .&/7d 
Xlank you fix the  opportunityto reviewand wmment on your draft repo~  Cost Sharing 
Undc# the OlderAmericans Act.  We are pleased with the attention and quick turn around 
provided by your Office of Evaluation and Inspections. 
As you know,  the Older Americans Act (Act) does not permit cost sharing.  State agencies 
admbktering  programs undct the Acthavecxprcsscda desiretoknplentmtsome~  of 
wstsharinginprogramunder the Ad fbr ow  20 years, and manyare involvedin wat 
sharingstrategicalaspermittedunderotherfederalandstateprogram  In recognitionof this, 
and to fwWtW enhxwd  coordinationof programs under the Actwithother human and 
social smite  program,  we are promoting in the current reauthorization proposal the option 
for statesto allow cost Waringfix some scnices. 
The comprehensive survey developed and administered by Jean DuFresne,  and the 
coordination  provided  by David Wright  has provided  us with the necesary  background 
inf~tion  _  to assess  cost  sharing  language in rcauthorizatioo  bills propoad  by the 
@Ori~  ixIbQth the ~OIUE and m,  We also anticipate  that this survey  data  W  P1ovidc 
Us with bt@ine  iIlfOlmsltiOStlo dCvCIOPprogram  poticy  and techni@  aSSiStilrl& for state 
agencies  admkdstaing  program5  under  the Act. 
.  n~