The cost and policy implications of changing the current provision of community-based care for adults with severe disabilities are considerable and require a broad understanding of the current framework under which adults with disabilities receive services. This report (1) estimates the number and characteristics of adults with severe disabilities; (2) quantifies the federal assistance available to such individuals; (3) describes Medicaid coverage of personal care and related services; and (4) discusses how a sample of selected states have implemented Medicaid policies that allow consumers to select their own caregivers, an approach called consumer direction.