State Utilization of Direct Support Professionals in Medicaid HCBS Waivers.

Friedman (2019) sent a survey to every state Medicaid office. The team asked how much each state pays direct support professionals (DSPs) for personal-care tasks in HCBS waivers. They also asked what rules states use to set the rates.

The survey covered waivers that serve adults and children with intellectual or developmental disabilities. No clients were tested; this was a pure policy scan.

Reimbursement rates swing wildly. Some states pay DSPs twice what others pay for the same 15-minute unit of care. Most rates sit close to minimum wage.

Low pay creates a hidden cost: high turnover and empty shifts. When DSPs quit, waiver clients lose hours of help with bathing, meals, and community outings.

Berkovits et al. (2014) first clocked DSP wages at about $11.25 an hour. Friedman (2019) updates that picture by showing the state rules that keep wages stuck.

Yamaki et al. (2019) found that switching adults with IDD to Medicaid managed care cut ER visits. Carli’s data hint at one reason: under-paid DSPs may miss early health changes, driving later ER use.

Byiers et al. (2025) show Black children with Down syndrome get less therapy. Carli shows states set low DSP rates. Both papers expose Medicaid service gaps, just at different points in the system.

If you write behavior plans that rely on DSP carry-through, low pay can sink your program before the first trial. Use Carli’s state-by-state table when you lobby waiver managers for higher billing codes. Show them that raising the DSP rate by even one dollar buys staff stability, which in turn protects the consistency your behavior plan needs.