How North Dakota pays for disability services

Waiver inventory

Excluded: ND.0273, the Medicaid Waiver for Home and Community Based Services, serves people who are aged 65 and older or adults 18 to 64 with physical disabilities, brain injury, or dementia, with 821 unduplicated participants in year 1 rising to 1,356 in year 5. The application states it does not serve people with intellectual or developmental disabilities. hhs.nd.gov

North Dakota has no 1915(k) Community First Choice option and no I/DD-specific 1115 demonstration identified in the sources retrieved. A children's waiver page exists at hhs.nd.gov but its content was not retrievable.

State-only funded programs

Per the DD provider manual, North Dakota funds a narrow set of DD services entirely from the General Fund "in limited circumstances only when a service does not qualify for federal Medicaid financial participation or an individual does not qualify for the ICF/IID level of care." Eligibility requires DD Program Management eligibility under state administrative code plus documented need.

• Corporate Guardianship. Guardianship services for people with DD who lack a family or private guardian. Administered by HHS Developmental Disabilities Section. Appropriation not found.
• Section 11 Funds. State General Fund payments for residential and employment services for people who do not qualify for the waiver or for services with no federal match. The manual notes there are no standard service authorization forms; the DD Residential and Vocational Administrator works with regional program administrators to identify eligible individuals. Appropriation not found.
• Family Subsidy Program. Listed on the HHS overview of services for people with developmental disabilities as a distinct program providing financial assistance to families. The dedicated program page returned a 404 and no payment amount, eligibility rule, or appropriation was retrievable. hhs.nd.gov

Source for Corporate Guardianship and Section 11: hhs.nd.gov

County / regional / local funding

None identified. North Dakota has no county levy, county board, or local mill levy dedicated to I/DD services. The sub-state structure is eight state-operated Developmental Disabilities regional offices, staffed by Developmental Disabilities Program Managers who handle intake, eligibility, service planning, provider referral, and monitoring. DD Program Management is claimed as a Medicaid administrative activity under the waiver rather than billed as a provider service. Regional office directory: hhs.nd.gov

Funding scale

• FMAP, FFY 2026: 50.99 percent, the statutory floor. North Dakota is the lowest-match state of the three in this set, meaning roughly half of every DD service dollar is state money. kff.org
• Provider inflation, 2025-27 biennium: 2 percent per year for human service providers, applied to all DD rates. Nursing facilities excluded. ndlegis.gov
• Life Skills and Transition Center (the state institution at Grafton), 2025-27 biennium: $55,639,421 salaries and wages plus $12,707,658 operating and capital, total $68,347,079. Same source.
• Waiver capacity: 6,980 unduplicated participants in waiver year 1, growing by 150 per year to 7,580 in year 5. hhs.nd.gov
• Reserved capacity within the waiver: 15 emergency slots, 170 infant development slots, 5 supported employment slots. Same source.
• Waiting list: the state does not report a public waitlist count. Common slots are filled first-come, first-served; when common slots are exhausted, applicants who do not meet reserve capacity criteria are placed on a waiting list. Same source. No published count, average wait, or explicit statement of zero was found.
• Residential settings, from the CMS-approved statewide transition plan (2014 to 2018 assessment): 615 residential habilitation settings assessed, of which ISLA 488, MSLA 50, SLA 38, TCLF 25, congregate care 3, Family Care Option III 11; 96 provider-owned community residences required compliance changes; 12 adult foster care homes serving 16 waiver recipients statewide. medicaid.gov
• Total annual I/DD spending all funds, DD waiver spending, state versus federal split in dollars, and per-participant spending: not found. There is no separate DD line item in the 2025-27 appropriation bill; DD funding is embedded in the Human Services Division grants and LSTC lines.

Residential funding detail

North Dakota funds Residential Habilitation as the core 24-hour service, paid on a daily basis. The rate is built from direct care wages, relief staffing, employer related expenses, a vacancy factor, and administrative or program support costs, then adjusted by a funding percentage. Three Residential Medical Acuity levels sit above the base rate for people with higher medical need. ICF/IID is a separate state plan per diem with base, Medically Involved, and Medically Intensive tiers. Adult Foster Care and AFC Respite are delivered by Qualified Service Providers rather than licensed DD agencies. Host Home was added effective Jan. 1, 2026. Family Care Option pays a family member or family-like caregiver in the home.

Payment structure is a daily unit for Residential Habilitation, ICF/IID, and residential respite; hourly or 15-minute for Independent Habilitation and In-Home Supports; hourly for day and employment services. Authorized service hours are derived from an assessment score: the Supports Intensity Scale for people 16 and older (reassessed every 36 months) and the Inventory for Individual and Agency Planning for people under 16 (reassessed every 12 months), with the score multiplied by a service-specific formula. Teams may file an outlier request (Form SFN 1835, or SFN 1853 for Individual Employment) when the assessment-derived hours are inadequate.

Room and board is not state-funded and falls to the person's own income. The provider manual sets the limit: "Charges to individuals must not be greater than the individual's Supplemental Security Income less a predetermined amount for personal incidental expenses, plus the average dollar value of Supplemental Nutrition Assistance Program benefits received." Personal incidental expenses are valued at $135 for people in group homes. A retainer of up to 30 calendar days per year per participant is payable for temporary absences to hold staffing.

Source: hhs.nd.gov

Comparable service rates

North Dakota publishes rates as a build-up matrix rather than a flat fee schedule. The matrix carries columns for base wage, employer related expenses at 35.1 percent, staff relief percentage and dollars, program support factor, and a funding percentage. Figures below are the loaded values in the matrix effective July 1, 2026, which includes the 2 percent legislatively approved inflationary adjustment. For Residential Habilitation and Day Habilitation the intermediate "PS + Sub" column reads $40.48 and $44.01 respectively, at 91.6 and 100.0 percent funding, so the two figures are different columns of the same worksheet, not competing rates.

Official rate schedule links

• DD rate matrix effective July 1, 2026, including the 2 percent inflationary adjustment: hhs.nd.gov
• DD Provider Manual, with service definitions, units, authorization periods, room and board rules, and a reference to "Rate Guidelines and Matrix, Appendix B": hhs.nd.gov
• Draft 1915(c) IID/DD waiver application, amendment effective Jan. 1, 2026: hhs.nd.gov
• SPA ND-25-0021, 2 percent Medicaid provider rate increase effective July 1, 2025, approved by CMS Oct. 14, 2025: medicaid.gov

Notable features and flags

• Jan. 1, 2026: waiver amendment D took effect, adding Host Home as a residential option. This is the state's first formal host home model in the DD waiver. hhs.nd.gov
• July 1, 2026: rate matrix reissued with a 2 percent inflationary adjustment, the second year of the 2025-27 biennial 2 percent provider inflation. hhs.nd.gov
• April 1, 2024 renewal: respite became a stand-alone service limited to 600 hours per state fiscal year; the environmental modification cap rose from $20,000 to $40,000 per five-year waiver period; vehicle lifts and ramps became reimbursable; Parenting Supports was removed for lack of utilization; emergency slots were extended to transitions from state hospitals and skilled nursing facilities; capacity grows by 150 slots per year. hhs.nd.gov
• Oct. 14, 2025: CMS approved SPA ND-25-0021, a 2 percent inflationary increase across most Medicaid provider categories retroactive to July 1, 2025. medicaid.gov
• 2025-27 biennium: the Life Skills and Transition Center is funded at $68.3 million, a significant institutional footprint for a state with roughly 7,000 waiver participants. ndlegis.gov
• Provider capacity flag: only 12 adult foster care homes serving 16 waiver participants statewide were assessed under the statewide transition plan, suggesting the non-agency residential market is very thin. medicaid.gov

Confidence

Solid: waiver control number, amendment date, capacity trajectory, reserved capacity composition, the July 1, 2026 rate matrix values for residential, day, and employment services, the 2 percent biennial inflation, the room and board formula and the $135 personal incidental allowance, the assessment-driven hour allocation, the FMAP, and the confirmation that ND.0273 does not serve people with I/DD. Estimated or needing care: the rate matrix is a build-up worksheet with eleven columns, and I have reported the loaded column values while naming the intermediate column values for the two services where I could read the full column set. Anyone using these numbers for a rate comparison should open the matrix and confirm which column their comparison requires. Could not find: any published waiting list count, total DD spending all funds, DD waiver expenditures, per-participant cost, the Family Subsidy Program payment amount and appropriation, Corporate Guardianship and Section 11 appropriations, and published rates for respite, in-home supports, adult foster care, host home, and homemaker. North Dakota has no separate DD appropriation line and no DD data dashboard, so program-level spending is not publicly disaggregated.

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