The best states to start an IDD provider agency, judged by what Medicaid pays for in-home and community living supports, are South Carolina, South Dakota and Massachusetts. South Carolina ranks 1st of the 29 states compared at $21.49 per 15 minutes, or $85.96 an hour, 146.2% above the national median of $34.92. South Dakota ranks 2nd at $17.32 ($69.28 an hour) and Massachusetts 3rd at $17.01 ($68.04 an hour).
IDD services are among the widest-ranging in Medicaid. The top state pays $85.96 an hour for in-home supports and the bottom state $12.40, and in six states the rate does not cover a direct support worker's loaded wage. This guide ranks states on the in-home and community living supports rate, compares it with local wages, and explains how each state pays. Rates are one input to a location decision. Licensing, provider enrollment, staffing, payer mix and competition all need local research.
The table ranks the ten states that pay the most for in-home and community living supports. Most states publish a 15-minute rate; Delaware publishes an hourly one. Margin per hour is the hourly rate minus the median worker wage after employer costs.
| State | Rate | Rank | Margin per hour |
|---|---|---|---|
| South Carolina | $21.49 per 15 min ($85.96/hr) | 1 of 29 | $60.33 |
| South Dakota | $17.32 per 15 min ($69.28/hr) | 2 of 29 | $43.78 |
| Massachusetts | $17.01 per 15 min ($68.04/hr) | 3 of 29 | $36.71 |
| Alaska | $15.46 per 15 min ($61.84/hr) | 4 of 29 | $30.36 |
| Maryland | $15.33 per 15 min ($61.32/hr) | 5 of 29 | $29.93 |
| Delaware | $60.49 per hour | 6 of 29 | $33.43 |
| Colorado | $12.82 per 15 min ($51.28/hr) | 7 of 29 | $19.58 |
| Iowa | $11.59 per 15 min ($46.36/hr) | 8 of 29 | $18.13 |
| Maine | $11.26 per 15 min ($45.04/hr) | 9 of 29 | $13.32 |
| North Dakota | $10.43 per 15 min ($41.72/hr) | 10 of 29 | $10.97 |
The top six stand apart: each pays more than 70% above the national median. After Delaware, the rate drops to $51.28 an hour in Colorado, and margins fall below $20 an hour.
South Carolina Medicaid pays $21.49 per 15 minutes for in-home and community living supports, or $85.96 an hour. That ranks 1st of the 29 states compared and is 146.2% above the national median.
The median wage for the comparable direct support occupation in South Carolina is $18.54 an hour, only 29.8% of the rate. After a loaded wage, the margin is $60.33 an hour, the largest in the ranking by a wide gap.
South Carolina pays these supports directly, outside managed care, so the published rate is what you are paid. With the highest rate, the widest margin and no plan contracts to negotiate, South Carolina is the clearest Medicaid case in this ranking. Before committing, research the waiver and service requirements an agency must meet to bill this support, and provider enrollment, waiver capacity and waiting lists in the regions you would serve.
See every IDD rate on the South Carolina IDD Medicaid rates page.
South Dakota pays $17.32 per 15 minutes, or $69.28 an hour, ranking 2nd of the 29 states compared and 98.4% above the national median.
The median worker wage is $18.44 an hour, the lowest in the top 10, at 36.8% of the rate. That leaves $43.78 an hour after a loaded wage.
We have no managed-care rule on file for IDD supports in South Dakota, so ask the state how claims are paid. For an agency weighing the state, the questions are local: the distances staff would drive, how many people in your area are enrolled in an IDD waiver, and how hard it is to recruit direct support staff.
See the South Dakota IDD rates page.
Massachusetts pays $17.01 per 15 minutes, or $68.04 an hour, ranking 3rd of the 29 states compared and 94.8% above the national median.
The median worker wage is $22.66 an hour, 46.0% of the rate, and the margin after a loaded wage is $36.71 an hour. The rate is nearly level with South Dakota's, but the higher wage leaves a smaller cushion.
Massachusetts pays IDD supports directly, outside managed care. That makes the published rate a reliable revenue figure. Research the state's provider qualification process and how services are authorized, since both affect how quickly a new agency can begin billing.
Details are on the Massachusetts IDD Medicaid rates page.
Alaska pays $15.46 per 15 minutes, or $61.84 an hour, ranking 4th of the 29 states compared and 77.1% above the national median.
The median worker wage in Alaska is $22.77 an hour, the highest in the top six, taking 50.9% of the rate. The margin after a loaded wage is $30.36 an hour.
We have no managed-care rule on file for IDD supports in Alaska. A high wage narrows the margin, and the margin figure does not include travel, which can be a significant cost for in-home supports in any spread-out service area. Look carefully at where the people you would serve live before you commit.
See the Alaska IDD rates.
Maryland pays $15.33 per 15 minutes, or $61.32 an hour, ranking 5th of the 29 states compared and 75.6% above the national median.
The median worker wage is $22.70 an hour, 51.2% of the rate, leaving $29.93 an hour after a loaded wage. Maryland and Alaska are almost identical on rate, wage and margin.
Maryland pays IDD supports directly, outside managed care, so the published rate is the rate you collect. As everywhere, find out how long provider enrollment takes and what the state requires of direct support staff before you plan a start date.
Read more on Maryland IDD Medicaid rates.
Delaware pays $60.49 an hour, ranking 6th of the 29 states compared and 73.2% above the national median.
Delaware's median worker wage is $19.57 an hour, 44.7% of the rate. That leaves $33.43 an hour after a loaded wage, more than Alaska or Maryland despite a slightly lower rate.
Delaware pays these supports directly, outside managed care. With a rate close to the top five and a lower wage, Delaware is the strongest margin outside the top three. Research the state's provider enrollment process and the size of the waiver population you would serve. Delaware shows that a rate a few dollars below its neighbors can still produce a better margin when local pay is lower, which is why the margin column matters as much as the rank.
See the Delaware IDD rates page.
At the bottom of the ranking, the IDD rate falls below what it costs to employ a worker.
Louisiana ranks 29th of the 29 states compared at $3.10 per 15 minutes ($12.40 an hour), 64.5% below the national median. The median wage takes 191.8% of the rate, a margin of -$11.38 an hour. West Virginia pays $3.38 ($13.52 an hour), a margin of -$12.60, and Idaho $3.86 ($15.44 an hour), where the wage takes 204.7% of the rate and the margin is -$16.17.
Texas pays $18.47 an hour, a margin of -$12.02. Arizona pays $4.73 per 15 minutes ($18.92 an hour), a margin of -$8.15. Nebraska pays $20.07 an hour, a margin of -$5.81.
A low rate for this one service does not mean every IDD service in the state pays poorly. Check the state page for every IDD rate before writing a state off.
States are ordered by their Medicaid rate for in-home and community living supports for people with intellectual and developmental disabilities, ranked among the 29 states compared. Rates published per 15 minutes are converted to an hourly figure.
Worker wages are median hourly wages from Bureau of Labor Statistics data for the closest comparable occupation, where available. The margin takes the hourly rate and subtracts that wage after employer costs such as payroll taxes and benefits. It is a gross figure before supervision, travel and administration.
Every rate is compiled from official state Medicaid publications, and each one on the site links to its source document. See the methodology for how services and units are matched.
IDD services are mostly delivered through home and community-based waivers, so a high rate is only valuable if you can enroll as a provider and receive referrals. The rate tells you what an hour of support earns. It does not tell you:
- how many people in your area are enrolled in a waiver, or waiting for one;
- how authorizations and service plans are approved, and how long that takes;
- what training, background checks and supervision the state requires of staff;
- how many agencies already compete for the same people and workers.
Staffing is usually the binding constraint. A margin built on the median wage assumes you can hire at that wage. If other employers in your area pay more, your real margin will be lower.
IDD is unusual: in most top states the state pays supports directly, outside managed care. That is true for South Carolina, Massachusetts, Maryland, Delaware, Colorado, New Jersey and Oregon. For a new agency, it means the published rate is the rate you collect, without plan contracts to negotiate.
There are exceptions. In Iowa, plans must pay at least the published rate, so the fee schedule is a floor. In Arizona, the state sets the rate plans pay, which at $18.92 an hour is a low fixed figure.
South Dakota, Alaska, Maine and North Dakota have no managed-care rule on file for this service. Ask the state how claims are paid in those states before you budget.
Most IDD agencies offer more than one service, and the leaders differ. National medians:
- Community integration and community access: $26.70 an hour.
- Day habilitation and day programs: $23.14 an hour.
- Prevocational services: $18.67 an hour.
A state that ranks modestly on in-home supports may pay well for day programs or community access, so compare every line you plan to offer.
Begin with the IDD Medicaid rates by state hub to compare every IDD service. Then open the state pages on your shortlist, such as South Carolina, South Dakota, Massachusetts and Delaware, to see each rate with its source.
For full access while you build a budget, see pricing. The methodology page explains how rates are compared.