1 

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

COST SHARING UNDER


THE OLDER AMERICANS ACT


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JUNE GIBBS BROWN 

Inspector General 

MAY 1996 

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 OIG’S 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 AoA’s 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 -

Z’wmcmzsharing 

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 fortheidktqtogreat 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 l’lth 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 AoA’s 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 year’s 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 State’s 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

FINDINGSAND 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 State’s 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 State’s only M) 

4

Table I 

WfltJregate 

meal 

AK ! P 

CA P 

cT I P 

DC P 

GA ~ P, 

HI P 

ID P 

IL es 

IN P 

KS 

KY P 

IAl P 

MA P 

MD P 

ME P 

MN P 

Mo P 

ND ? 

NE ? 

NH P 

NJ ? 

NM P 

Nv P 

NY P 

o H P 

o R P 

PA P 

RI P 

Sc P 

so P 

VA P 

? 

VT P 

WA ? 

WI ? 

P ~~ 

TOT 1 

States that Cost Share, By Type of Service 

home del. in-home in-home adult day transpt. legal case other ! meal I medical pemonal care I asst. ~ mgt. P P P Cs P P Cs CS (respite)
 P P P es P P P
 Cs es es es P P es
 P P P es P P P(heatth promotion+)
 es es es es es P P
 P’ es P P P P P(escoft)
 P es P P


Cs es P P(senior wmpanion) es es es es es P c: 

es 

es P es es P P P CS (respite+) es P es P P P P 

es es es es Cs P CS (alzheimer) P es es es es Cs c! 

P es Cs es P P es P es es es es P P P es es P P P P 

? 7 ? 7 ? ? ?? 

es P P es P P P 

? ? 7 ? ? ? 7? 

P 

P 

P es es P P = c S (respite) 

? ? ? ? ? ? ?? 

P es P P P 

P P es P P P Pc S (respite+) 

P P Cs Cs P P P 

P 

P 

es 

es 

es 

P 

es 

es 

es 

es 

P 

P 

Pc S (attendant) 

Cs Cs Cs P P P 

P Cs Cs P P P 

P Cs Cs P es P p

Cs es es es P p

? ? ? ? ? ? ?? P P Cs es es P PP (?) - ? ? ? ? ? ? ? ? ? ? I ?!7 ? ?? 

p es ! es ~ p P Cs 

9 12 24 I 21 11 1 7 6 

5 

VI 
.

I I 

Y 

Table 2 Voluntaw Contributions by Service and State 

WWregate home del. in-home in-home adult day transpt. Iega( ~= other 

AK : 

meal 

xx 

meal medical personal care ~ asst. mgt.

AL I x I x 

1 x x! PI 

AR ] x x 

x p(health promotion)
 x
 Azj x ! x x x x x X(home modification+)
 PA “ 1 .. x X1X x x x )qmsmcA– – . .. elnm mool~ 

:: Yfm : I 

x x Ix _x x x ! x ;.., ,, 

CT . . x ‘X: 

Xj)( 

xix x x x XIY! ,, 

DC x x x	

x x x x I

DE ~ x x P

x
 x x x X(hlth pImmo/retreat.) x .

Y I v I “ FL x x 

A 

.. A P


GA X’)( 

x I x I A x x x [x(w)
 v


HI x 

Xj)( .

Y I A I v I -.A I w :=


IA x 

x Pj x x x x x X(esUM/recreation+)


ID x 

x x x x x P P
 x


IL x 

x x P P 

IN} x lx, 

x 

x~~ 

x x x x x x X(info. & assist.)

Ks x x 

x x P P 

KY x X1X 

x

I

x lx x x x


M x x 

x x x P


MA x x 

x x P P 

“,- ... MD x x x 

I n I v I iwneann promotion) 

ME x x P P I

x ; 1 P I I


MI x 

P XIXID1 1 I I


MN x 

x x x x I X1X x
 n x P x Y~v’-’ I A I A 1 

‘1 

I 

Mo x x ..

M x X1X1X1 x~ s x x 

MT x )x x x P
 x x x x NC ] x I x x x x


ND

x x x )x x x x
 x x
 x
 NH x x

1X1X1 . . J! ‘Dfinfn-’-’ \!sllwllluwuucau
 ‘--””?) x x x x 1 x I 

I 

lv/mA..----..,- A..- NJ x lq=uvvwGy/muc.+) 

NM x 

x x x I x X1X 1 x I

,,., Y(%,, 

NV x 

x P x P x XIP IX(nacniia’ x P - ) x I P x XIP 

I-.1.--r.. 

OH

NY 

x 

x


x 

x x x x x x P


OK x x 

x 2( x x P(?)


OR x x x
 x ,x P x X1X1)(I .- x~
 PA x “ )( x x
 RI x x P P 1 P 

x 

) 

x x P x(?) 

Sc x x 

P P P


SD x x x x P
 x x P P x

f

I v 1 “ 

TN I P
 x x


Tx x x 

x x ; ; x I


\lA , . . x x


; ; x 

x 

x

x 

x

x x x 

x 

x 

x x 

x X(LTC COOfd.) 

WA x x 

x x x x X(advoc.kounq

WI x 

x x x x P x x Xix
 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 offWithin 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 recipient’s 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 recipient’s 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 recipient’s 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 potentialitiesof 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 lowincome 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 recipient’s 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 “X”NEXT 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 costshareornfJt~. 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


state has 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 AAAsJLPs’proposed 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 SECI’ION I - CURRENT COST SHARING PRACI’ICES 

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 don’t 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— 

Congregate Meal 1 28 1 I 11 

Homedelivered Meal 2 19 9 8 

In-home SeMces (Medial - skilled 8 10 12 9 

nursing, physical therapy, etc.) 

In-home Setiees 

errands, etc.) 

Adult Day Care 

Transportation 

Legal A&stance 

Case Management 

Othec (PLEASE 

To@: 

(Penonal -housewdq o 5 24 14 

1 8 21 I ] 14 

1 18 11 

2 26 1 

1 19 7 

SPECIIW) 1 5 5 1 

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 

some people pay the same set fee bti on seMw pro~d~, after ~ruing

an income threshold. �KS, MO, NY, RI, VT, WY 22 6* 1

People pay different fees for different sefi~, b& on in~me, wing 1* 28 2** 

a 

“sliding-scale” fee sch~ule.*MA **CA ~ 

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 client’s 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.) 

ACI’ION NO YES DK 

State bills client and collects mat shared funds. *SD, RI +~ 27 2* 1+ 

AAA bills client and State collects cost shared funds. +CT 12810 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+ 

Othec (PLEASE SPE~) � DC -client pays contractor 4* 

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 T’fMEOF 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/


dressing in the home 10 1 9 (-j 1 7


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 

MO-RN visitand ~ personal, KS-senior care act 2 + 

+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. A’TTACH 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 

Collected funds 

Collected funds 

level.”~ @ ~ 

CQlkted funds 

NY, 0~ PA ~ 

COllected fimds 

programt*MO, 

NO YES DK 

are spent only on the same type of service.*KY, NY 2* ~ 3 

are used to of&et administrative rests at State/local 18 7* 4 

NV, ~ VA VT 

are used to oftket expenses for other seMces.*MO, ~ 16 7* 6 

VA 

are used to offset expe~ m other State/local 20 5* 4 

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 PRACI’X~


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 REPOR’IS OR OTHER DOCUMENTATION SENT TO YOU BY f%%%~ps 

WHICH EXPLAIN THE ABOVE LISTED $$$S, AND ANY OTHER COST REPORTS 

FORMULATED BY THE STATE FOR Accounting FOR AND TRACKING VOLUNTARY 

COLLECTEDFUNDS. 

A-n 
13. Does the State or any AAAWPS use any fee scheduledincome requirements to determi

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 SU

taken any of the following actions: 

Action NO YES


Provide guidance to AAAs/LPs to help them develop fee schedules and 20* 2g


procedures.*~m~DC,~G&m ID, II+ IN, NL%MD, MN,


Review AAAa/LPs’ proposed fee schedules and procedures. �& AR, CO, 22*


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


24 
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. 

ACI’ION 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

SECf’ION 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 

Clmgregate Meal 

Assist with bathing/ 

dressing in the home 

Respite Care 

Home-health seMces (skilled nursing, physical 

therapy, etc.) 

Emergency response/alert 

Friendly calldvisits 

Light housework 

Errands/shopping 

Handyman/minor home repair 

Transportation 

Legal assistance 

Adult Day Care 

Case management 

Counseling 

Other (PLEASE SPECIIY) 

16 12 21 

17 17 16 

21 6 21 

23 5 21 

24 7 14 

23 7 12 

22 21 5 

19 6 24 

19 9 21 

22 6 21 

18 6 26 

23 6 21 

19 5 24 

23 13 11 

22 10 9 

2 

A-17

WA WY 

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


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 M

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%’of 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. 

- -., .. 1 P-ON 

<1000 

1001-1050 

1051-1100 

1101-1150 

1151-1200 

1201-1250 

1251-1300 

1301-1350 

;’	 1351-1400 

1401 = 1450 

1451-1500 

1501-1550 

1551-,1600 

1601-1650 . . 1651.1700 

1701-1750 

SLIDING FEE SCALE 

Adjusted income 

2 PERSONS 

<13(3(3 

1301-1350 

1351-1400 

1401-1450 

1451-1500 

1501.1550 

1551-1600 

1601-1650 

1651-1700 

1701-1750 

1751-1800 

1801-1850 

1851-1900 

1901-1950 

1951-2000 

2001-2050 

1751-,~fOQ - 2051-3000 

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

18S1 -,1900 3051-4000 

,,’, 

Cost per hour 

no chge 

1.50 

2.00


~.jo


3.00


3.50


4.00


4.50


5,00


5.50


6.00


6.50


7.00


7,50


8.00


8.50


. . 9.00 - ..-

9.50


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 

INDIVIDU- “ $946 per month 

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 

2) The amount of the housing adustment can 

the following maximum amounts: 

INDIVIDUW = $189 per month 

COUPLE. 000 = $253 per month 

C. Cost Share Rate Schedule 1 

T COUPLE 

lNDIVIDUM 

Fe. 

Fee Adjusted 

J@jUSte~ Rate Income Rate 

Income . Ot 

� * o % $0 

$0 5 % $1 to $44 “ “ ~:: 

$1 to $33 “ 

10 % $45 to $89 

158 $34 to $66 15 4 $goto S133 2ot $67 to S1OO 20 8 $134to $177 .258 $101 to S133 

$134to $166 “ “ “; % ::::: :~~ “ “ ::: 

$167t0 $*99 3 58 $267 tO $311 408 

$200to $232 4 O* $312to S355 45$ $233to S26~ 4 58 $356to $399 

$266t0 S299 $400 to S444 “ “ “; ;; 

S300 to $332 � � � 

;;: s445 tO s488 6 0% $333 to $365 608 $489t0 S532 6 58 $366 to S3- 658 $533 to S577 7 Ot 

$399 to S431 70% $578t0 $621 . .7 5* 

$432 to S46~ 808 

S466- $498 � � � :% x:= :::: � 85% $499 to S531 85% $711 to S754 908 

S532to S564 908 $755to S799 

$565 to $597 95% ;:: 

$598 to S631 100? zzZ%ans~;~3* 1 

More than S631* 

b 

� Or eligible for Medicaid. 

OFA NO. 282 (revised 12/94) 

B-3 
APPENDIX C 

AoA’s 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 Act have cxprcsscda desire to knplentmt some ~ of 

wstsharingin programunder the Ad fbr ow 20 years, and manyare involvedin wat 

sharing strategicalas permittedunder otherfederaland stateprogram 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 P1’ovidc 

Us with bt@ine iIlfOl’msltiOSlto dCvCIOPprogram poticy and techni@ aSSiStilrl& for state 

agencies admkdstaing program5 under the Act. 

. n~