How South Dakota pays for disability services

Waiver inventory

South Dakota's other two 1915(c) waivers, HOPE (SD.0189.R08.00) and Assistive Daily Living Services (SD.0264.R06.00), serve older adults and people with physical disabilities and are excluded here. South Dakota has no 1915(i), 1915(b)(3) or 1915(k)/Community First Choice authority for the IDD population in the sources retrieved. CMS SD waiver factsheet; SD HCBS overview

State-only funded programs

From the SD DDD Resource Guide, which lists these separately from the Medicaid waiver programs and states that services operate through Medicaid and state general funds:

• Community Training Services (CTS): pre-vocational training, community living training and expanded follow-along for people who need minimal supports and are not on a waiver. Thirteen providers serve across regions. Administering agency: DHS Division of Developmental Disabilities. Annual appropriation not published in the sources retrieved.
• Strengthening Families Program: reimburses families for eligible goods and services including incontinence supplies, medications, adaptive equipment and housing modifications. No service coordinator is assigned. Administering agency: DHS Division of Developmental Disabilities. Annual appropriation not published in the sources retrieved.
• Respite Care Program: temporary relief care for family caregivers, covering children and adults with developmental disabilities, chronic medical conditions, serious emotional disturbance or traumatic brain injury. This is broader than the DD population. Administering agency: DHS Division of Developmental Disabilities. Annual appropriation not published in the sources retrieved.

Checked: the DDD Resource Guide, the CHOICES and FS360 billing manuals and fee schedules, the 2025 rate review and the 2025 legislative interim committee report. Dollar appropriations for these three state-only programs are not published in any of these; the legislative report and rate reviews cover only the two Medicaid waivers.

County / regional / local funding

None identified. South Dakota has no county DD levy, county board of developmental disabilities, regional center allocation or local mill levy for this population. Services are delivered by a statewide network of nonprofit Community Support Providers (23 for CHOICES, 8 for FS360, 13 for CTS) contracting directly with the state, financed by Medicaid and state general funds. Checked the DDD Resource Guide, the CHOICES billing manual, the 2025 rate reviews and the 2025 legislative interim committee report on Community Support Providers; none identifies a sub-state funding stream. The legislative report is explicit that for providers "Medicaid is their primary source of revenue." 2025 legislative report on Community Support Providers

Funding scale

• Total DD spending, FY2025: $251.9 million across both waivers. CHOICES $241.2 million ($193.5 million residential, $47.7 million non-residential); Family Support 360 $10.7 million. 2025 legislative report on Community Support Providers
• CHOICES waiver expenditure trend, from the rate review's own accounting (SFY2025 measured June 2024 to May 2025): SFY2025 actual $229,296,556; SFY2026 projected $234,333,824; SFY2027 projected $256,241,279, a 9.3 percent increase. Residential is $190,388,261 of the SFY2025 total and $212,294,717 of the SFY2027 projection, roughly 83 percent. CHOICES 2025 Rate Review
• State vs federal share: for the SFY2027 projection, state share $126,275,343 and federal share $129,705,486 across residential and non-residential (residential $104,724,984 state / $107,569,733 federal; non-residential $21,550,359 state / $22,135,753 federal). Roughly 49 percent state. The SFY2027 rate increase alone requires $21.9 million, of which $10,806,948 state and $11,100,508 federal. Same source.
• FMAP: 51.01 percent FY2026 (53.07 percent FY2025). South Dakota's FMAP fell about two points year over year, which raises the state share of every waiver dollar. MACPAC Exhibit 6
• Spending per participant: not published as such. CHOICES at $241.2 million across 2,690 adults implies roughly $89,700 per person in FY2025; FS360 at $10.7 million across 1,420 people implies roughly $7,500. Both are calculations, not published figures.
• People served in DD waivers: 4,110 total (2,690 CHOICES, 1,420 FS360). 2025 legislative report
• Waiting list: 198 people on the Family Support 360 waiting list, average wait approximately eight months. The same report identifies no waiting list for CHOICES. Same source.
• Rate funding gap: for FY2026 the state funded 94.9 percent of the reimbursement methodology for providers, meaning benchmark rates were not fully funded. Same source.

Residential funding detail

South Dakota funds four residential models under CHOICES, all defined in the CHOICES billing manual and priced on the CHOICES Waiver Fee Schedule effective June 1, 2026. Payment is a daily rate that varies on two axes simultaneously: an acuity tier 1 through 6 based on the person's ICAP service score, and the size of the home, 1 through 8 or more residents. This produces a full matrix rather than a single per diem, and it is the distinguishing feature of the South Dakota system.

• Group Home (Level One), T2016, provider-owned or controlled, staff maintain round-the-clock responsibility with a minimum of 10 hours of daily staff presence. Tier 1 ranges from $1,099.82 per day in a one-person home down to $319.97 at four people and $215.49 at eight or more. Tier 6 ranges from $1,099.82 at one person down to $518.04 at four people and $446.30 at eight or more. The steep decline with home size is an explicit economies-of-scale adjustment.
• Supervised Living (Level Two), T2025, provider-owned or controlled, staff present a minimum of 6 hours daily, for people who do not need overnight coverage. Tier 1 $182.87 per day at sizes 1 through 4, declining to $143.08 at eight or more. Tier 6 $339.16 at size 4, declining to $288.78 at eight or more.
• Supported Living (Level Three), T2017, intermittent support in a home, apartment or shared family home the participant owns or leases. Cannot be delivered in a provider-controlled setting. Billed hourly rather than daily: $17.32 per 15 minutes.
• Shared Living Residential Habilitation, T2016 U7, delivered in the private home of a community member or friend, maximum two participants per residence, and family members may serve as providers. Daily per diem by occupancy: $196.11 (1) rising to $277.31 (6). The billing manual describes shared living as a daily per diem stipend of $120 to $195 depending on ICAP tier paid through to the home provider.

Room and board is not state-funded and falls to the individual. The CHOICES billing manual states that payments explicitly exclude "room and board, the cost of facility maintenance, upkeep and improvement," with limited exceptions for modifications needed for health, safety or life safety code compliance. In practice this is covered by the person's SSI.

ICF/IID: two private ICF/IID facilities operate in South Dakota, serving approximately 44 residents per day based on 15,994 annual Medicaid bed days. The current per diem is $822.00, with a proposed SFY2025 benchmark of $921.31, an increase of about 12 percent, costing $1.6 million of which $658,377 state funds. The state also operates the South Dakota Developmental Center at Redfield. ICF Rate Study; ICF billing manual

Family Support 360 funds no residential service. It supports people living in the family home or their own home, and nearly all its services are paid at billed charges up to a monthly cap rather than a fixed rate: personal care up to $3,500 per month, respite up to $2,500, companion care up to $3,500, supported employment up to $2,000, home modifications up to $15,000, specialized medical equipment up to $10,000. The only fixed rate is Service Coordination at $22.01 per 15 minutes. FS360 Fee Schedule effective July 1, 2026

Rate structure link: CHOICES Waiver Fee Schedule, effective June 1, 2026

Comparable service rates

CHOICES rates from the fee schedule effective June 1, 2026, labeled "FY27 Rate" in the source. FS360 rates from the fee schedule effective July 1, 2026.

Official rate schedule links

• CHOICES Waiver Fee Schedule, current, effective June 1, 2026
• Family Support 360 Waiver Fee Schedule, current, effective July 1, 2026
• SFY27 Family Support 360 Waiver Rates
• CHOICES Waiver FY25 Rates
• SD Medicaid fee schedules index
• CHOICES 2025 Rate Review
• CHOICES 2024 Rate Review
• CHOICES Case Management and FS360 Service Coordination Rate Review
• ICF/IID Rate Study
• CHOICES billing manual

Notable features and flags

• July 1, 2026: Conflict-free case management takes effect for CHOICES at $16.88 per 15 minutes, a structural change explicitly dated on the fee schedule. The billing manual already bars case managers from simultaneously providing other waiver services. CHOICES Fee Schedule
• 2025 rate review, for SFY2027: proposed benchmark rates average a 9.6 percent increase over SFY2026 published rates (10 percent over existing SFY2026 rates), requiring $21.9 million additional, $10.8 million state and $11.1 million federal. Methodology components are a 4.26 percent inflation adjustment, supplemental pay at 3.92 percent, administrative costs at 14.3 percent of wages, program support at 20 to 29 percent of wages depending on service, and a 94 percent occupancy adjustment. Rates are set by legislative appropriation, so the benchmark is a proposal, not a guarantee. CHOICES 2025 Rate Review
• FY2026 underfunding: the state funded only 94.9 percent of the reimbursement methodology. Providers testified repeatedly through the 2025 legislative interim that the methodology is not fully funded and that Medicaid is their primary revenue source, a direct provider capacity flag. 2025 legislative report
• FMAP decline: South Dakota's regular FMAP fell from 53.07 percent in FY2025 to 51.01 percent in FY2026, shifting roughly two points of every waiver dollar onto state general funds at the same time the rate review calls for a 9.6 percent increase. MACPAC Exhibit 6
• January 6, 2025: DHS held a CHOICES Waiver Amendment town hall. The amendment changed vendor qualification rules to make out-of-state care easier to access. The deck confirms CHOICES is traditional, not self-directed; self-direction in South Dakota runs through Family Support 360. CHOICES Waiver Town Hall slide deck
• Waiting list asymmetry: CHOICES has no reported waiting list, while Family Support 360 has 198 people waiting an average of about eight months. Since FS360 is the self-directed, family-home waiver and the cheaper of the two, the queue sits on the lower-cost side of the system. 2025 legislative report
• ICF/IID rate proposal: a 12 percent increase from $822.00 to $921.31 per diem was recommended, costing $1.6 million with $658,377 state share, across just two private facilities serving about 44 residents per day. ICF Rate Study

Confidence

Solid: every CHOICES rate in the comparable services table, extracted verbatim from the fee schedule PDF including procedure codes, modifiers, tiers and home sizes; the FS360 billed-charges structure and monthly caps; the tier-by-home-size residential matrix and the three residential levels with their staffing thresholds; the room and board exclusion; the FY2025 spending totals of $251.9 million combined, $241.2 million CHOICES and $10.7 million FS360; the SFY2025 to SFY2027 CHOICES expenditure series and its state/federal split; the 2,690 and 1,420 enrollment counts; the 198-person FS360 waiting list with an eight-month average wait; the 94.9 percent methodology funding level; the FMAP; the ICF/IID per diem and facility count. Estimated: the two per-participant figures, which I computed from published totals and headcounts rather than sourced. Also worth flagging that the CHOICES fee schedule is labeled "Effective June 1, 2026" while its rate column is headed "FY27 Rate," and the conflict-free case management line separately carries "Effective 07/01/2026," so the effective dating within that single document is internally inconsistent; I have reported it as printed. Could not find: annual appropriation amounts for the three state-only programs (Community Training Services, Strengthening Families, Respite Care), which appear in the DDD Resource Guide by description only; a current resident count, budget or operational status for the South Dakota Developmental Center at Redfield, since the DHS page for it is a JavaScript application that returned no content and search access was exhausted; a CMS-published unduplicated participant cap for either DD waiver.