How do cash and counseling programs work?

How do cash and counseling programs work?

Short answer: “Cash and counseling” is an older name for self-directed care: the person receives a budget to hire their own caregivers, often including family, with help from a counselor or fiscal agent.

Figures change periodically. Double-check current amounts before relying on them.

“Cash and counseling” began as a national demonstration in the late 1990s and early 2000s. Today these programs are usually called consumer-directed, self-directed or participant-directed care.

How they generally work:

  • A budget. After an assessment, the person (or a representative) receives a monthly budget based on their care needs.
  • Hiring. The person hires, trains, schedules and supervises their own caregivers, who can often be family members or friends (rules on paying a spouse vary).
  • A fiscal agent handles payroll, taxes and paperwork.
  • A counselor or support broker helps with planning and problems.
  • Flexibility. Some programs let part of the budget be used for related goods and services.

Self-direction is available through many waivers and some state plan programs. The VA has a similar program, Veteran Directed Care.

Getting help

Every situation is different, and small facts can change the answer. If this question affects a real decision, especially with a spouse at home, a home, gifts or a trust, a Certified Medicaid Planner can apply your state’s rules to your situation. As a rough guide, published fees for help with an application range from about $500 to $6,000, and hourly help from about $150 to $600.

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.

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