Mental and Behavioral Health, and Crisis Services for People with Intellectual and Developmental Disabilities in Medicaid Home- and Community-Based Services.
Medicaid waivers set aside almost one billion for mental-health services for people with IDD, yet states spend it very differently, so your client’s access depends on where you practice.
01Research in Context
What this study did
Friedman et al. (2025) looked at every Medicaid HCBS waiver for people with IDD in FY 2021. They pulled out the dollars listed for mental-health and crisis services. The team counted 190,299 waiver users and nearly one billion set aside for therapy, ABA, and crisis help.
What they found
The money is there, but it is not spread evenly. Some states fund strong behavior teams and 24-hour crisis beds. Others list almost nothing for mental health. The same waiver can look very different once you cross a state line.
How this fits with other research
Friedman et al. (2015) saw the same patchwork eight years earlier. Their survey warned that mental-health lines in waivers were often blank. The new FY 2021 numbers show the gap is still wide, so the problem is long-term, not fixed.
Friedman (2023) counted the whole pie: $43.2 billion for 861,038 people with IDD. The 2025 paper slices out the mental-health piece and finds it is less than three cents of every waiver dollar. Together the two studies prove most money still goes to room and board, not therapy.
Lakin et al. (2010) tracked the historic shift from big institutions to home-and-community waivers. That move opened the door for therapy funding, but the 2025 data show the door is only partly open.
Why it matters
If you write behavior plans, you already fight for hours. This paper gives you hard numbers to show why the fight exists. Use the state-by-state tables when you ask for more authorized hours or crisis respite. Point out that nearby states already fund it, so your request is reasonable.
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Join Free →Print your state’s waiver mental-health line item and compare it to the highest-funded state in the paper—use the gap to justify a funding request at the next ISP meeting.
02At a glance
03Original abstract
People with intellectual and developmental disabilities (IDD) often have higher rates of comorbid mental health conditions compared to the general population. Yet, many people with IDD also have unmet needs for mental and behavioral health services. The aim of this study was to examine how states provided mental and behavior health, and crisis services to people with IDD in their Home- and Community-Based Services (HCBS) programs, the largest funding mechanism for Long-Term Services and Supports (LTSS) for people with IDD in the United States. We analyzed fiscal year (2021) Medicaid HCBS waivers for people with IDD from across the United States to examine if and how they provided mental and behavior health, and crisis services. States projected spending $968.9 million for mental and behavior health, and crisis services for 190,299 people with IDD. Applied behavior analysis services were provided at greater rates than positive behavior supports and other forms of behavior interventions. While most states provided mental and behavior health, and crisis services in their waivers, there were vast inconsistencies in how they did so, across states, waivers, and services. HCBS are a crucial safety net to ensure people with IDD, especially those who also have mental health disabilities, can live and thrive in their communities.
Journal of autism and developmental disorders, 2025 · doi:10.1176/appi.ps.202200022