Cost-sharing and the future of fees for service for frail elders in state programs

Although Congress has rejected the concept of mandatory cost-sharing under the Older Americans Act, many states already use client fee systems under state-funded home and community-based services programs. This research included a survey of actual state experiences and a review of earlier studies. States are compared on issues concerning policy and experience with fee systems, including income verification, fee schedules, termination policies, and costs of administration. Although policy and practice differ markedly across states, certain states are close to operationalizing comprehensive policies in this area. The author concludes that there is a need to conduct additional state-level demonstrations that address policy issues identified in the research. Evaluation research is needed to determine program effectiveness and efficiency, particularly concerning whether cost-sharing increases the amount of services available and ensures a high level of services to minorities.