<strong>Home and Community-Based Services for Older People and Younger Persons with Physical Disabilities in Alabama</strong> Author(s)/Publisher/Date: Prepared by Joshua Wiener and Susan Goldenson for the U.S. Department of Health and Human Services, Health Care Financing Administration (June 6, 2001). <strong>Key concepts/Target audiences:</strong> This report details the state of Alabama’s home and community-based service system for older people and younger persons with physical disabilities. It focuses on the state administrative structure, eligibility and assessment, services covered by Medicaid and other programs, and quality assurance. This information is useful to state policy makers, agency administrators, program planners, and service providers. <strong> Summary:</strong> Data were obtained from a number of sources including public documents, state of Alabama web sites, and interviews with state officials, provider associations, and other stakeholders. The state’s long-term care system is dominated by nursing home care, with home care accounting for a small proportion of Medicaid expenditures. There is little funding for noninstitutional services external to the Medicaid program. The Medicaid program funds two home and community-based services waiver programs for older people and those with disabilities: the “elderly and disabled” waiver which serves a disabled population and the “homebound” waiver which serves primarily a younger population with severe disabilities. The majority of daily administration is carried out by the Alabama Department of Public Health and the Alabama Department of Senior Services. Waiver services are traditional and do not include consumer-directed home care or non-medical residential care. <strong>Administrative Structure:</strong> The non-waiver home and community-based services, principally home health, are directly administered by the Alabama Medicaid Agency. This agency contracts with the Alabama Department of Public Health and the Alabama Department of Senior Services to administer the elderly and disabled waiver and with the Alabama Department of Rehabilitation Services to administer the homebound waiver. The state agencies pay the state Medicaid match for the waiver services they assume. Providers bill the state Medicaid agency and Medicaid then provides payments to the administering agency which then pays the provider. For the elderly and disabled waiver, the caseload is divided between the Department of Public Health and the Department of Senior Services. The Department of Public Health is the administering agency for approximately two-thirds of waiver beneficiaries and the Department of Senior Services is the administering agency for the remaining one-third of beneficiaries. The Department of Public Health serves as a Medicare-certified home health agency and is the largest and main provider of home health services in the state. It also administers the waiver by providing case management, developing plans of care, and helping clients choose direct service providers. It is also a direct provider of non-skilled home care services including homemaker, companion, personal care, skilled and unskilled respite care, and adult day care services. The Department of Senior Services is the state unit on aging and administers programs funded through the Older Americans Act and part of the Medicaid elderly and disabled waiver and uses the thirteen AAAs to administer the waiver. It is not a direct provider of services. The AAAs provide case management and billing services for the organizations that provide services. The Department of Rehabilitation Services administers the State of Alabama Independent Living Services (SAIL) program, which focuses on younger adults with disabilities. <strong>Eligibility Criteria and Assessment:</strong> Eligibility criteria is composed of financial and medical/functional standards. With respect to financial criteria, Alabama enrolls all Supplemental Security Income beneficiaries in the regular Medicaid program but does not have a medically needy program. Financial eligibility for the elderly and disabled are less restrictive. For the elderly and disabled and homebound waivers, beneficiaries must meet the nursing facility level of care but there are no other standards that assess the risk of institutionalization. The homebound waiver targets a narrower population including persons aged 18 and older with physical disabilities not associated with the process of aging and with onset prior to age 60. <strong>Services:</strong> Alabama covers a very narrow range of home and community-based services through its Medicaid program. Services covered under the elderly and disabled waiver include case management, adult day health services, homemaker services, personal care services, respite care services and companion services. The homebound waiver provides case management services, personal care, respite care, environmental accessibility adaptations, personal emergency response systems, medical supplies, and assistive technology. Home health is strictly medical in nature and there is an absolute limit on the number of visits per year. The Department of Rehabilitation Services offers a much more flexible set of services through its own small programs and through the homebound Medicaid wavier but the target population is narrow and limited to the non-elderly population. Services in non-medical residential facilities are not covered services under the waivers, and the waivers do not offer consumer-directed care. <strong>Quality assurance:</strong> Quality assurance practices and regulations focus on home health agency certification, case manager visits with clients, internal quality assurance mechanisms among the three state departments responsible for administering services, and on-site reviews of case management including review of records, plans of care, and narrative records documenting outcomes of care. Because the policy and administration for long-term care are spread across four agencies, there is duplication of effort in quality assurance practices.