In Alabama:
  • As of July 1, 2011, there were 930,736 beneficiaries enrolled in the state’s Medicaid program, 568,332 of whom were enrolled in the primary care case management program known as Patient 1st.
  • Physical, behavioral, and oral health services are provided through Patient 1st and reimbursed on a fee-for-service basis. Certain Medicaid populations are excluded from this program, including dual eligibles, recipients residing in a residential or institutional facility, and recipients with developmental delays or impaired mental conditions.
  • Medicaid eligible individuals ages 3 and older who would otherwise require the level of care available in an intermediate care facility for Individuals with Intellectual Disabilities (ICF/IID) can apply to receive services through two state waivers:
    • Home- and Community-Based Waiver for Persons with Intellectual Disabilities, which provides residential habilitation services, including day habilitation, physical therapy, personal care, skilled nursing, and behavior management; and
    • Living at Home (LAH) Waiver for Persons with Intellectual Disabilities, which includes in-home residential rehabilitation, personal care, and personal care transportation.
As of 2013, 605,305 individuals were eligible for Alabama’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), known in the state as the Well Child Check-Up Program. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 62% and a participant ratio of 54%. 293,440 children received dental services of any kind, with 278,533 receiving preventive dental services.
Last updated September 2014
Medical Necessity
The Alabama Medicaid Agency uses the federal statutory definition for medical necessity. The state requires that medical necessity be documented in a beneficiary’s medical record with supporting documentation such as: Laboratory test results, diagnostic test results, history (past attempts of management if applicable), signs and symptoms, etc. All Medicaid services are subject to retrospective review for medical necessity.
Initiatives to Improve Access
Reporting & Data Collection
Behavioral Health
The Alabama ABCD Screening Academy Project worked to spread structured developmental and social emotional screening in primary health care practices. Through this project, the state expanded Medicaid reimbursement for standardized screening, and sustained and spread the use of validated, objective screening tools. More information regarding the state’s ABCD efforts can be found here.
Alabama Medicaid allows qualified providers to bill for Intensive Developmental Diagnostic Assessments (using the 96110 and 96111 CPT codes) for children under age two. These assessments are performed by multidisciplinary teams and may include both developmental screening tests and early language milestone screens (as well as interpretation and reporting of results).
Support to Providers and Families
Support for Providers:
The Alabama Medicaid Agency operates an EPSDT website which contains information for providers, including billing information, administrative code, provider agreement forms, a provider manual, and a reference sheet on periodic screenings.
The Alabama EPSDT provider manual includes information on the state’s patient education method, known as PT+3, developed to assist providers who work with illiterate or marginally literate patients and families. The method’s standardized protocol is meant to give providers the skills needed to help young or marginally literate patients remember points from a health care visit and increase knowledge and compliance.  EPSDT, Patient 1st, and Medicaid family planning providers who receive training in PT+3 are eligible to receive free low literacy materials for children, teens, and adults.
Support for Families:
Alabama’s EPSDT website also contains resources for parents and families, including contact information for care coordinators, education materials, and other facts sheets.
Care Coordination
Patient 1st:
The Alabama Medicaid Agency operates the Patient 1st program, which creates a medical home for Medicaid recipients by linking them with a primary medical provider (PMP). Participating PMPs receive a monthly care management PMPM for coordinating care for Medicaid recipients in their practices. Each PMP provides and arranges for each recipient’s health care needs, and is required to provide EPSDT preventive care screenings to Medicaid eligible children. PMPs serving this population who do not provide EPSDT services are required to sign an agreement with another provider to provide EPSDT services.
Patient Care Networks
Alabama has enhanced the Patient 1st  primary care case management program by creating regional  Patient Care Networks. These nonprofit organizations supplement provider capacity for care coordination by assuming responsibility for “implementing a plan of care … for each [Medicaid] participant that includes coordination of care through collaboration with the member, family, primary care physicians, specialists, community resources, and pharmacists.”
A Section 2703 Health Homes state plan amendment approved in 2013 allowed Alabama to incorporate additional comprehensive care management services into the Patient Care Networks for Medicaid beneficiaries with two or more of the following conditions: asthma, diabetes, heart disease, cardiovascular disease, chronic obstructive pulmonary disease, cancer, HIV, mental health conditions, substance abuse disorder, sickle cell anemia, or organ transplant.
Alabama is currently building off of the Patient Care Network concept by planning the launch of Regional Care Organizations (RCOs). RCOs will be risk-bearing organizations that are responsible not only for providing comprehensive Medicaid benefits (including EPSDT services) and securing medical homes for all enrolled Medicaid beneficiaries in a region, but also for coordinating care across settings.
Care Coordination
The Alabama Medicaid Agency partnered with the Department of Public Health to initiate an EPSDT care coordination service for private and public providers. The program assists provider offices with identifying, contacting, coordinating, and providing follow up for children who are behind on EPSDT screenings and immunizations. Care coordinators are also available to assist with transportation services using Alabama’s Medicaid Non-Emergency Transportation (NET) program.
Oral Health
1st Look
In partnership with the Alabama Chapter of the American Academy of Pediatrics, the Alabama Academy of Pediatric Dentistry, and the Alabama Dental Association, the Alabama Medicaid Agency operates the 1st Look Program. The collaborative program is designed to reduce early childhood caries by “encouraging primary care physicians to perform dental risk assessments, provide anticipatory guidance, apply fluoride varnish when indicated, and refer children to a dental home by age one.” Children who have already seen by a dentist do not qualify for this program.