How Hawaii pays for disability services

Waiver inventory

Hawaii operates a single I/DD waiver. There is no separate autism waiver, no children's I/DD waiver, and no 1915(i) or 1915(k) authority for this population identified in any source retrieved.

State-only funded programs

• Long-Term Adult Services and Resources (LASR). A state-funded program for people age 18 and older who are not eligible for Medicaid I/DD Waiver services but are eligible for DDD services. Served 52 people in FY2025, 1.48 percent of DDD's caseload. Administering agency: Hawaii Department of Health, Developmental Disabilities Division. Annual appropriation: not separately published. Official URL: health.hawaii.gov
• Case Management Only. DDD provided case management without waiver services to 249 people in FY2025, 7.06 percent of the caseload. This is DDD-administered service coordination outside the waiver benefit. Administering agency: DOH DDD. Official URL: health.hawaii.gov
• Adult Foster Home supplemental payments. DDD pays supplemental incentive payments to Residential Habilitation agencies that place participants into newly certified adult foster homes on the neighbor islands. Two payment triggers: first participant placed in a home not certified within the prior six months and remaining 120 days; second participant placed within one year of certification and remaining 120 days. This is a network-development incentive targeting the neighbor-island provider shortage, not a room and board subsidy. Payment amounts are not published on the form. Administering agency: DOH DDD Outcomes and Compliance Branch. Official URL: health.hawaii.gov
• Workforce Development Training Incentive Program. State-funded training incentives for direct support professionals and service supervisors. Administering agency: DOH DDD. Official URL: health.hawaii.gov

County / regional / local funding

None identified. Hawaii's four counties (Honolulu, Hawaii, Maui, Kauai) have no health or human services financing role; the state administers all public health and social services directly. There are no county DD boards, no county levies for disability services, and no regional center allocations. DDD operates through 15 regionally based case management units, which are state units, not local funding bodies. I checked the DDD program pages, the July 2026 waiver application, the 2025 evaluation report, and the Department of Budget and Finance program structure documents; none reference county or local revenue for I/DD.

Funding scale

• Total I/DD waiver spending, FY2023: $160 million. This grew from $102 million in FY2015, an average annual growth rate of 5.8 percent, driven primarily by rate adjustments rather than caseload growth. health.hawaii.gov
• Hawaii FMAP, FY2027: 58.39 percent federal, so roughly 41.61 percent state share on matched spending. kff.org
• People served, FY2025 (July 1, 2024 to June 30, 2025): 3,525 total DDD participants, of whom 3,002 (85.16 percent) were Medicaid waiver participants, 249 (7.06 percent) case management only, 52 (1.48 percent) LASR state-funded, and 214 (6.07 percent) not reported. 2,792 (79.21 percent) had authorized services, totaling 8,371 service authorizations. health.hawaii.gov
• Approved waiver capacity: 2,998 unduplicated participants in waiver year 1 (FY2027), 3,056 in year 2 (FY2028), 3,115 in year 3 (FY2029). Note that FY2025 actual waiver enrollment of 3,002 already sits at year-1 capacity. health.hawaii.gov
• Spending per participant: approximately $59,500 all funds for FY2023, derived from $160 million divided by 2,688 FY2023 service users. Derived, not published. health.hawaii.gov
• Waiting list: none. The 2025 independent evaluation states flatly that "DDD does not have a waitlist for waiver services," and the July 2026 waiver application confirms individuals "are admitted as soon as they are approved," with expedited processing for crisis situations. Hawaii is one of a small number of states with no I/DD waiver waiting list. health.hawaii.gov and health.hawaii.gov
• Caseload flow: roughly 155 participants start services and 120 stop each year, a net gain of about 35 per year. FY2020 peak was 2,842 service users; FY2021 fell 8 percent to 2,610 during the pandemic; FY2023 recovered only to 2,688, still below pre-pandemic. health.hawaii.gov
• Case management capacity: approximately 80 case managers statewide across 15 regional units, average caseload 35 participants against a national benchmark of about 24. health.hawaii.gov
• FY2026 and FY2027 DDD (HTH 501) appropriation by means of financing: not found. See Confidence.

Residential funding detail

Hawaii funds residential support through Residential Habilitation (ResHab), available only in licensed or certified homes, plus Additional Residential Supports as an hourly add-on. 735 participants (20.85 percent) had ResHab authorized in FY2025. Overall, 798 people (22.64 percent) lived in licensed or certified settings, 2,558 (72.57 percent) lived with family, and 167 (4.74 percent) lived independently. Hawaii's system is unusually family-based by national standards.

Payment structure: per diem for the residential setting, quarter-hour for add-on supports.

1. Adult Foster Homes (AFH), Tiers 1 through 3. $117.32 to $234.08 per day. Codes S5140, T2016, T2033. An AFH is a certified caregiver's own home serving no more than two adults with a developmental or intellectual disability. This is Hawaii's dominant shared-living / host-home model and the reason the family-home share of the population is so high.
2. Licensed Homes, Tiers 1 through 3. $130.92 to $234.08 per day. Codes T2016, T2033. Slightly higher at the bottom tier than AFH, converging at the top tier.
3. Adult Therapeutic Living. $642.32 to $648.93 per day. Code T2033. This is the high-acuity tier, priced roughly 2.8 times the top standard residential per diem.
4. Additional Residential Supports. $7.60 to $7.85 per 15 minutes. Codes T1004, T1019, 99600. Layered on top of the residential per diem for individually assessed needs.
5. Crisis Shelter. $1,050.00 per day, code T2034, for Waiver Emergency Services out-of-home stabilization. Crisis Intervention mobile outreach is $52.50 per 15 minutes.

Tiering basis. Tiers 1 through 3 reflect assessed support need. Hawaii also prices Registered Behavior Technician (RBT) delivery separately across most service lines, which is a distinctive feature: an RBT 1:1 hour costs the same ($15.00 to $17.37 per 15 minutes) whether delivered in Personal Assistance, Adult Day Health, or Community Learning Service.

In-home and family settings. Funded through Personal Assistance/Habilitation (PAB), Respite (family home only), Chore, and Non-Medical Transportation. PAB, Chore, Respite, Non-Medical Transportation, and Community Learning Service are all available through the Consumer-Directed Option with a Financial Management Services contractor.

Room and board. Not waiver-funded. The July 2026 waiver application states that "FFP is not claimed for the cost of room and board," with two narrow exceptions: room and board provided as part of respite services in a state-approved facility, and the portion of rent and food reasonably attributed to an unrelated caregiver residing in the same household. Room and board therefore falls to the participant's own income, principally SSI. I did not find a Hawaii state supplemental payment specifically covering room and board in DDD residential settings.

New in the 2026 renewal. The waiver adds Personal Care Assistance and Residential Care Supports as new services, and restructures Discovery and Career Planning, Individual Employment Supports, Community Navigator, and Training and Consultation.

Rate structure link: health.hawaii.gov

Comparable service rates

All rates from the I/DD Waiver Rate Sheet effective July 1, 2025. Ranges reflect tier and island/geographic differentials.

Additional lines on the same sheet: Private Duty Nursing RN 1:1 to 1:2 $12.22 to $26.44 per 15 min (T1000), LPN $6.71 to $14.43; Chore $8.41 to $9.34 per 15 min (S5120); Non-Medical Transportation $1.90 to $6.00 per mile or trip (S0215).

Official rate schedule links

• health.hawaii.gov
• health.hawaii.gov
• health.hawaii.gov
• health.hawaii.gov
• health.hawaii.gov
• health.hawaii.gov
• health.hawaii.gov (linked as the attachment to transmittal CRB-FY2024-06 on health.hawaii.gov the archive lists it at health.hawaii.gov)
• health.hawaii.gov

Notable features and flags

• July 1, 2026: CMS approved the waiver renewal HI.0013.R09.00 for a three-year period through June 30, 2029, with capacity rising from 2,998 to 3,115 participants. The renewal adds two new services, Personal Care Assistance and Residential Care Supports, and restructures Discovery and Career Planning, Individual Employment Supports, Community Navigator, and Training and Consultation. health.hawaii.gov and health.hawaii.gov
• July 1, 2025: Updated I/DD Waiver rate sheet took effect (transmittal CRB-FY2026-02, issued 7/8/25), following a June 30, 2025 memo announcing a delay in the service code and modifier updates. The July 2025 change was primarily a service code and modifier restructuring rather than a rate increase; DDD did not publish percentage changes. health.hawaii.gov
• January 2026: Waiver Amendment #12 approved by CMS, preceding the July 2026 renewal. health.hawaii.gov
• October 2025: An independent evaluation of DDD ("Moving Forward") found the provider network stable but with limited provider availability outside Oahu, DSP wages up markedly with turnover down following the rate increases, and rate updates well received after roughly 12 years without adjustment. It also flagged case manager caseloads at 35 against a benchmark of 24. health.hawaii.gov
• Employment underperformance flag, October 2025: Hawaii's integrated employment rate is 5 percent against a national average of 24 percent, and employment services consume 1.8 percent of the day services budget versus 9.4 percent nationally. This is the sharpest structural weakness the evaluation identified. health.hawaii.gov
• No waiting list, but capacity is binding. FY2025 actual waiver enrollment of 3,002 already exceeds the FY2027 approved capacity of 2,998. With net growth of about 35 people per year and approved capacity growing about 58 per year, the no-waitlist position holds only if that flow pattern persists. health.hawaii.gov and health.hawaii.gov
• Neighbor-island residential capacity: DDD pays incentive supplements to residential agencies that stand up new adult foster homes on the neighbor islands, an explicit response to the geographic provider gap. health.hawaii.gov

Confidence

Solid: the complete July 1, 2025 rate sheet, extracted line by line from DDD's own transmittal attachment; FY2025 caseload, funding-category, living-arrangement, and service-authorization counts from the DDD Data Factbook 2025; the waiver number, three-year period, and year-by-year capacity from the July 2026 waiver application; the no-waitlist finding, confirmed independently by both the 2025 evaluation and the waiver application; and the FMAP from KFF. Reasonably solid: the $160 million FY2023 waiver spending and the FY2015-FY2023 growth series, which come from a DOH-commissioned independent evaluation rather than a budget document, and which are now three fiscal years stale. Estimated: the $59,500 per-participant figure, which is my own division of FY2023 spending by FY2023 service users. Could not find: the FY2026 or FY2027 HTH 501 Developmental Disabilities appropriation by means of financing. HTH 501 does not appear in the FY25-FY26 Health variance report, is only listed as a heading in the FB25-27 program and financial plan, and does not appear in the intermediate program structure document; the FY2027 Executive Supplemental Budget in Brief contains no DD line. Also could not find: Appendix J cost-neutrality factors (the posted waiver application PDF truncates mid-Appendix B-6); the dollar amount of the AFH supplemental payments; LASR's appropriation; ICF/IID census or rates; percentage change figures for the July 2025 rate update; and a citable URL for Hawaii's QUEST Integration 1115 demonstration, which I have described only in general terms and which should be verified before use.