How Missouri pays for disability services

Waiver inventory

Consolidated waiver summary with services, caps, CMS-372 counts and costs: dss.mo.gov

State-only funded programs

All figures are FY2026 Governor's Recommended, general revenue only, from the Department of Mental Health appropriation book: oa.mo.gov

• Autism Regional Projects. $9,017,135, 100% general revenue, no federal or other funds. Five regional autism projects providing applied behavior analysis, parent training, life skills, social skills, respite, music therapy, occupational therapy, speech therapy, and counseling statewide. Approximately 7,300 people served each fiscal year. Administered by DMH Division of Developmental Disabilities, bill section 10.410.
• Community Non-Medicaid Programs (GR). $17,064,053 FY2026, general revenue only. Non-Medicaid DD community services delivered through the regional office system. Listed in DMH's flexibility request table.
• Autism Outreach Initiatives. $51,511, general revenue only.
• Springfield Autism Center, Joplin Autism Center, Autism Research, ATI-DD Training Pilot. All appear as named cores in the DD division but are budgeted at $0 in FY2026.
• State habilitation centers (Bellefontaine, Higginsville). ICF/IID facilities operated by DMH. Not state-only: they draw Medicaid. A related Habilitation Center Room and Board Fund carries $3,416,532 of appropriation authority in FY2026 for room and board receipts collected from residents, which the centers spend on expense and equipment for residents.

County / regional / local funding

Missouri's county developmental disability boards are the single largest sub-state DD funding stream in the three states covered here.

• Mechanism. Senate Bill 40 of 1969, codified at RSMo 205.968 through 205.972. With approval of a majority of voters, a county (or the City of St. Louis) may levy a property tax of up to 4 mills per dollar of assessed valuation, reduced to 2 mills for certain larger first-classification counties. Revenue goes into a special fund usable "for no other purpose": sheltered workshops, residences and facilities, employment programs, case management, transitional services, direct supports, housing, social centers, transportation, community inclusion, and Medicaid-related expenses. Statute text: revisor.mo.gov
• Governance. Nine-member board appointed by the county commission to three-year terms; at least seven must reside in the county; two must be related within the third degree to a person with a developmental disability; four are public members. ccddr.org
• Geography and scale. The Missouri State Auditor's 2008 statewide review found 85 of Missouri's 114 counties plus the City of St. Louis had established SB40 boards. Of those, 60 boards in third-class counties levied approximately $12 million in property taxes in 2007 with total receipts of approximately $25 million and cash balances of approximately $14 million. That review flagged accumulation of significant cash reserves without documented spending plans. auditor.mo.gov
• Current levy examples (Productive Living Board Partner Funding Manual, plboard.org):
• St. Louis County (Productive Living Board): 9-cent levy per $100 assessed valuation, over $23 million annually.
• St. Charles County: 16-cent levy, over $12.5 million annually.
• DD Resources (City of St. Louis): 15-cent levy, over $5 million annually.
• DD Advocates: over $3 million annually.
• State match interaction. DMH operates a Mental Health Local Tax Matching Fund (fund 1930) that lets local tax dollars stand as the state's Medicaid match. Fund 1930 is one of the "Other Funds" sources of the DD Community Programs core (Other Funds total $16,034,695 in FY2026); the appropriation book does not break out fund 1930 separately. The Partnership for Hope waiver is the clearest expression of this: it operates in 103 counties plus St. Louis City, matched with SB40 board dollars.
• Statewide association and member map: macdds.org and macdds.org
• Not found: a current statewide total of SB40 levy revenue, or a current count of participating counties. The 2008 auditor's figures are the most recent statewide aggregate located.

Funding scale

• DD waiver spending, waiver year 2024 (CMS-372): Comprehensive $1,859,945,768; Community Support $298,939,512; MOCDD $7,398,142; Partnership for Hope $6,767,192. Combined $2,173,050,614, serving 17,498 people across the four waivers. dss.mo.gov
• Comprehensive waiver spending trajectory: $959,228,220 (2020) to $937,998,308 (2021) to $1,148,997,496 (2022) to $1,546,311,276 (2023) to $1,859,945,768 (2024). Community Support: $107.6M (2020) to $298.9M (2024).
• DMH Division of Developmental Disabilities, all funds: FY2024 actual $2,340,367,610; FY2025 budget $2,583,988,208; FY2026 department request $2,894,785,514; FY2026 Governor recommended $2,820,511,411. DMH department total FY2026 Gov Rec $4,358,589,053. oa.mo.gov
• DD Community Programs core, FY2026 Gov Rec: $2,368,305,594 total, of which GR $843,713,212, federal $1,508,557,687, other $16,034,695.
• State vs federal share: DMH department-wide FY2026 Gov Rec is GR $1,744,871,975, federal $2,531,056,091, other $82,660,987. For the DD Community Programs core specifically the split is roughly 36% GR / 64% federal.
• FMAP: Missouri FY2026 64.44% (KFF). DMH's own budget book states the blended FMAP rate falls from 65.500% to 64.658% effective October 1, 2025, and books an FMAP adjustment decision item to cover the resulting GR increase. kff.org
• Spending per participant, Comprehensive waiver, waiver year 2024: approximately $204,800 (derived: $1,859,945,768 ÷ 9,080). Community Support waiver derived average approximately $44,900, which sits near its $42,000 per-person cap because the served count is unduplicated across a full year.
• People served in DD waivers, waiver year 2024: 17,498 across the four DMH waivers.
• Waiting list: none. As of 7/1/2026 DMH states "The Division is processing enrollments for ALL HCBS waivers currently" and "There is NOT a wait list for any of the Division's HCBS waivers currently." What exists instead is a processing list of 248 people statewide: 211 in-home (44 MOCDD, 167 Partnership for Hope and Community Support Waiver) and 37 on the Comprehensive waiver residential processing list, all of them Priority of Need 5 (crisis, verified under 9 CSR 45-2.017(1)(E)). Access is by PON score (1 through 5, driven by the Missouri Adaptive Ability Scale) then date added. dmh.mo.gov and dmh.mo.gov
• KFF reports 1,272 people with I/DD waiting in Missouri in 2025 (76 in 2024, 680 in 2023). This conflicts with DMH's own statement and appears to count the processing list plus pending enrollments. Treat DMH's figure as authoritative. kff.org

Residential funding detail

Residential support is concentrated almost entirely in the Comprehensive waiver. The Community Support, MOCDD, and Partnership for Hope waivers fund no ongoing residential service; Partnership for Hope has Temporary Residential Services only.

Services and payment structure (DD Waiver Manual, mydss.mo.gov):

• Group Home (T2016 HQ), Group Home-Intensive, Group Home-Transition. Unit is one day (24 hours). Per diem, tiered by acuity (MAAS score 1 through 5) and by home size (1 to 6 beds versus 7 or more beds). The per diem covers direct staff assistance across self-care, sensory/motor development, interpersonal skills, communication, behavior shaping, community living skills, mobility, health care, socialization, money management and household responsibilities; salary, benefits and training for direct and supervisory staff; habilitation supplies and equipment not prescribed to one person; staff supervision up to 24 hours per day; agency administration; and non-medical community transportation. Settings are provider-owned or controlled and must meet 42 CFR 441.301(c)(4)(vi). Staffing ratios are set in 9 CSR Division 40. Monthly Registered Nurse Oversight (1.25 hours) is authorized and billed separately, not inside the per diem.
• Individualized Supported Living (T2016). Unit is one day, but the rate structure is hourly staff time (per the rate study, ISL is priced per hour with acuity tiers and a home-size band of up to 4). ISL Transportation billed separately per mile (T2001, T2001 HE). ISL Nursing RN (T1002 TD) and LPN (T1003 TE) billed in 15-minute units.
• Intensive Therapeutic Residential Habilitation (T2016 HK). Per diem, up to 4 people, for people with the most intensive behavioral needs; requires evaluation by the Chief Behavior Analyst or designee with graphic display of intervention effects, reviewed at least annually.
• Shared Living (host home model). Two variants, both per diem with three acuity tiers: Shared Living Host (S5136) and Shared Living Companion (S5136 HR). The manual is explicit that "Payments for Shared Living do not include room and board, items of comfort or convenience, or the costs of home maintenance, upkeep and improvement," and that people receiving Shared Living cannot also receive Medicaid state plan personal care. Rate determination form: dmh.mo.gov
• Temporary Residential (H0045). Short-term residential, billed per day or per 15 minutes; the residential option in Partnership for Hope.
• Out-of-Home Respite (H0045, T1005). Delivered in a licensed or certified waiver residential facility, ICF/IID, state habilitation center, standalone facility, or Shared Living relief home.
• In-home and family settings. Personal Assistant (T1019, individual / group 2-3 / group 4-6 / medical exception), In-Home Respite (S5150 individual, S5150 HQ group, S5151 day), Individualized Skill Development, Community Networking, Remote Supports. People receiving Group Home, ISL, or Shared Living may not also receive Individualized Skill Development, because it is bundled into the residential service.
• ICF/IID. DMH operates state habilitation centers (Bellefontaine, Higginsville). oa.mo.gov
• Room and board. Excluded from waiver payment. The waiver manual lists "Room and board costs" as an excluded expense for residential services and for Shared Living, and Community Transition Services explicitly covers only setup costs "that do not constitute room and board." Residents pay from SSI and other income. The one exception in the appropriation structure is the Habilitation Center Room and Board Fund, which collects room and board from state habilitation center residents ($3,416,532 authority in FY2026) and returns it to the centers for expense and equipment supporting residents. There is no state room-and-board subsidy for community residential settings identified in the documents reviewed.
• ISL budget methodology: Individualized Supported Living Services and Budget Manual, dmh.mo.gov

Comparable service rates

Missouri does not publish a consolidated public DD fee schedule. Rate-setting authority sits with MO HealthNet, which sets "maximum allowable rates as recommended by DMH for all HCB supports" (9 CSR 45-3.080), but the DD rates do not appear on MO HealthNet's fee schedule page (https://dss.mo.gov/mhd/fee-schedules-rate-lists), the provider manuals page, or the DMH manuals page. The most recent official published rate table is Appendix B of the Mercer 2022 HCBS Rate Study, which lists rates effective July 1, 2022 alongside SFY 2024 modeled ranges. DMH's own budget book confirms the legislature has since approved four consecutive fiscal years of DD provider rate increases, so current rates are higher than the figures below; the current amounts are not published.

Official rate schedule links

• Mercer 2022 HCBS and TCM Rate Study, with Appendix B rate tables effective 7/1/2022 and SFY2024 modeled ranges: dmh.mo.gov
• DD Waiver Manual (current version, service definitions, procedure codes, units, and limits): mydss.mo.gov
• Waiver manuals index: dmh.mo.gov
• Shared Living Rate Determination Form: dmh.mo.gov
• Individualized Supported Living Services and Budget Manual: dmh.mo.gov
• MO HealthNet Fee Schedules and Rate Lists (does not currently carry a DD waiver schedule): dss.mo.gov
• DMH FY2026 Governor's Recommended appropriation book: oa.mo.gov
• Waiver summary with CMS-372 served counts and annual costs: dss.mo.gov

Notable features and flags

• No waiting list, as of 7/1/2026. DMH is processing enrollments for all four HCBS waivers. The residual 248-person processing list is entirely PON 5 crisis cases plus in-home applicants moving through eligibility. This is a significant national outlier and is the direct product of the waiver capacity increases visible in the CMS-372 maximums (Comprehensive from 9,196 in 2021 to 10,731 in 2025; Community Support from 5,572 to 8,901).
• Four consecutive fiscal years of DD provider rate increases through FY2026, plus "Provider Rate Standardization" in FY2023 and FY2024, per the DMH appropriation book. Spending in the Comprehensive waiver nearly doubled between waiver years 2021 and 2024 ($938.0M to $1.86B) on a 6% increase in people served, which is a rate and acuity story, not a caseload story.
• Comprehensive and Community Support waivers expire June 2026. Both are due for CMS renewal at essentially the moment of this profile; MOCDD and Partnership for Hope run to June 2028. Watch for renewal amendments.
• Partnership for Hope is contracting sharply. Served 2,085 in 2022, 1,912 in 2023, 1,445 in 2024, against an approved maximum of 4,259 for 2025. Annual cost fell from $10.3M (2023) to $6.8M (2024). This is the county-matched waiver, so the contraction has implications for SB40 board partnership arrangements. Meanwhile the Community Support waiver grew from 4,815 to 6,654 over the same period, suggesting migration from the $12,362 cap to the $42,000 cap.
• FMAP decrease effective 10/1/2025, blended rate from 65.500% to 64.658%, forcing a GR-side adjustment in the FY2026 budget.
• Rate transparency gap. Missouri publishes service definitions, procedure codes, and unit limits, but not current dollar rates. The last public rate table is dated 7/1/2022. Providers, families, and analysts cannot currently see what Missouri pays for a group home day or an ISL hour.
• Self-direction is available under 9 CSR 45-3.080, with individual budget allocation set as hours needed times the statewide base rate for comparable agency-based supports, capped at what the person would receive from an agency. Support Broker (T2041) and self-directed Personal Assistant (T1019 U2) and Community Specialist (T1016 U2) are billable.

Confidence

Solid: waiver inventory, waiver numbers, per-person cost caps, CMS-372 served counts and annual costs by waiver year 2020 through 2024, approved maximums through 2025, and expiration dates all come from DMH's own 11/14/25 waiver summary. The processing list detail and the explicit "no wait list" statement are from the 7/1/2026 DMH report PDF. Division and core appropriation figures are from the FY2026 Governor's Recommended DMH appropriation book, read directly. Service definitions, procedure codes, unit limits, and the room-and-board exclusion are from the current DD Waiver Manual. SB40 statutory mechanism and levy cap are from the statute itself. Estimated or secondary: current provider rates. Every rate in the table is effective 7/1/2022 from the Mercer study, and DMH's budget confirms four subsequent increases whose magnitudes are not published, so the true current rates are higher by an unknown percentage. Derived: per-participant Comprehensive waiver spending (approximately $204,800) is my own division of two DMH figures. Could not find: a current statewide total of SB40 levy revenue or count of active boards (2008 auditor data is the most recent aggregate); the amount of DMH Local Tax Matching Fund revenue; enrollment or residential coverage for the Complex Adult Waiver; any current Day Habilitation rate.

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