Medicaid Waivers are the largest expense for HCDDS, making up more than half of all spending. So, it’s helpful to understand what waivers are and how they work.

Waivers are a funding source for people with developmental disabilities to receive services they need in the community, instead of in institutions like nursing homes or intermediate care facilities. Waivers fund services like personal care, transportation, in-home support, home modifications, respite, and more. Eligibility rules, services, and rates are established by Medicaid at the state and federal level and cannot be altered or supplemented by HCDDS. Waiver enrollment is based on a standardized, state-mandated assessment and waivers are a lifetime commitment. Once someone is enrolled, they can only be disenrolled for limited, needs-based reasons.

A portion of funding for waivers comes from the state and federal governments. The remainder must be paid locally. Funding waivers is a core, state-mandated function of county boards – we’re required by law to pay our local waiver match. The benefit of this system is that every $1 in local levy funding we pay toward waivers unlocks approximately $4-$5 in combined state and federal dollars. That’s a great return on our local dollars that gets re-invested in Hamilton County and funds essential services for people in our community. 

HCDDS is spending more money than we’re bringing in each year for three key reasons:

1. 1. More people need services, and support needs are higher.
   2. The cost of services (Medicaid waiver rates) has increased.
   3. Our levy funding has remained flat since 2010.

The increasing cost of waivers is the most significant driver of our increased expenses, because we’re required by law to pay our waiver match and the cost of those waivers is set by the state and federal governments. The total cost of waivers is impacted by three major factors that have all increased:

1. 1. The match rate paid by the federal government. Throughout the pandemic, the federal government picked up a larger portion of these costs, but in state fiscal year 2024 the federal portion returned to pre-pandemic level. This increased the amount of money county boards were required to pay.
   2. The rates for Medicaid waiver services. From 2019 to 2025, the rate for direct support professionals (DSPs) increased significantly from an average of $11.12 per hour to an average of $19 per hour. This rate increase was essential to ensure people with DD could access services, that providers could hire staff, and that our DSPs were fairly paid – and HCDDS strongly supported this rate increase. But this change did increase the cost of waiver services.
   3. The number of people receiving waiver services. The number of people enrolled on waivers has increased by more than 500 since 2019. This has increased our waiver match costs.

Taken together, these factors have caused the average local match per waiver to increase from about $32,000 to more than $54,000 since 2019. Cumulatively, our total waiver match cost doubled between 2023 and 2025. By 2029, our required waiver match obligation will surpass our entire levy revenue. This one mandated service will require all our levy dollars, leaving none remaining for other required and critical supports. 

As our costs have increased, our funding has remained flat. In Ohio, county boards of DD including HCDDS, are funded through local property tax levies. We receive more than 80% of our funding from a single levy that generates about $79 million each year. By law, these levies do not receive additional funding when property values increase – they bring in a flat amount.

Our levy was last renewed in 2024. When a levy is renewed, it ensures funding continues, but it still brings in the same flat amount. The levy that funds HCDDS was last increased to adjust for inflation in 2009 and has been renewed at the same flat amount since then. This means we still operate on about the same funding as we did 16 years ago, despite significant inflation and significant increases in our required spending.

When our levy was last on the ballot, we had built a moderate cash balance due to a number of factors, including short-term pandemic relief funding. We knew that we would spend down that cash balance over the levy cycle. Commissioners and the Tax Levy Review Committee (TLRC) understood our financial projections and recommended annual reviews of our agency’s finances to monitor our finances and the rate at which we spent down our levy funding.

As expected, we’ve begun to spend down our levy fund balance. Now that we have a better understanding of our ongoing spending requirements, we’re able to work with the TLRC and commissioners to ensure our funding aligns with our mandated services and the needs of our community.

HCDDS has worked to stretch every tax dollar we receive as far as possible – providing incredible value to our generous and supportive homeowners in Hamilton County. Our ability to make this funding last is directly related to both system-wide trends as well as difficult decisions made by the Board and leadership of this agency. The major factor that have allowed us to operate on flat funding since 2010 include:

• • We reduced our budget: Despite the increase received in 2009, HCDDS was projecting a $15 million deficit by the end of the levy cycle in 2014. At that time, we reduced costs and make up the deficit by restructuring teams, freezing salaries, instituting early retirement incentive programs, changing rate payment processes, reducing contract costs, and increasing billing and school revenue.
  • We stretched every dollar further with matching funds: Based on recommendations from the TLRC, we focused aggressively on providing services through Medicaid waivers as much as possible in order to maximize state and federal match funding. When someone receives services funded through a waiver, every $1 in local levy funding HCDDS pays toward a waiver unlocks approximately $4-$5 in combined state and federal dollars.
  • We responded to system-wide changes: The required privatization of adult centers in 2017 resulted in decreased expenditures, including reducing the number of employees by 250 and salary and benefits by 30%. While HCDDS also lost the revenue from operating the adult centers, the change resulted in a net savings. Rather than reallocating funding, we deliberately built up our cash reserve in anticipation of changes to the waiver waiting list rule, which we expected to result in increased waiver enrollment. As we were completing that process, the state and federal COVID-19 response resulted in decreased waiver utilization cost, reduced waiver match cost, and increased one-time funding.

Taken together, these factors have allowed us to make our funding last without asking voters for additional revenue since 2009. 

HCDDS is spending more money than we’re bringing in each year for three key reasons:

1. 1. More people need services, and support needs are higher.
   2. The cost of services (Medicaid waiver rates) has increased.
   3. Our levy funding has remained flat since 2010.

The increasing cost of waivers is the most significant driver of our increased expenses, because we’re required by law to pay our waiver match and the cost of those waivers is set by the state and federal governments. The total cost of waivers is impacted by three major factors that have all increased:

1. 1. The match rate paid by the federal government. Throughout the pandemic, the federal government picked up a larger portion of these costs, but in state fiscal year 2024 the federal portion returned to pre-pandemic level. This increased the amount of money county boards were required to pay.
   2. The rates for Medicaid waiver services. From 2019 to 2025, the rate for direct support professionals (DSPs) increased significantly from an average of $11.12 per hour to an average of $19 per hour. This rate increase was essential to ensure people with DD could access services, that providers could hire staff, and that our DSPs were fairly paid – and HCDDS strongly supported this rate increase. But this change did increase the cost of waiver services.
   3. The number of people receiving waiver services. The number of people enrolled on waivers has increased by more than 500 since 2019. This has increased our waiver match costs.

Taken together, these factors have caused the average local match per waiver to increase from about $32,000 to more than $54,000 since 2019. Cumulatively, our total waiver match cost doubled between 2023 and 2025. By 2029, our required waiver match obligation will surpass our entire levy revenue. This one mandated service will require all our levy dollars, leaving none remaining for other required and critical supports. 

As our costs have increased, our funding has remained flat. In Ohio, county boards of DD including HCDDS, are funded through local property tax levies. We receive more than 80% of our funding from a single levy that generates about $79 million each year. By law, these levies do not receive additional funding when property values increase – they bring in a flat amount.

The levy that funds HCDDS was last increased to adjust for inflation in 2009 and has been renewed at the same amount since then. This means we still operate on about the same funding as we did 16 years ago, despite significant inflation and significant increases in our required spending.

We’re not waiting to act. While long-term sustainability will involve an increase in levy funding, likely on the November 2028 ballot, even getting to 2028 will require us to make strategic decisions now to protect services for the people who count on us. Right now, we’re focused on:

• • Reviewing our business practices and contracts to find savings that don’t impact direct services.
  • Maximizing every dollar of state and federal funding we’re eligible to receive.
  • Analyzing our current programs and services to stretch dollars as far as possible while continuing to meet needs.
  • Providing regular updates to Hamilton County’s Tax Levy Review Committee to share our current financial status and future funding needs.
  • Engaging with a statewide effort to update how Ohio funds DD services at the legislative level – because this problem does not just affect Hamilton County.

These efforts are already underway, and we’ll continue to build on this work in the coming years. Over the last 59 years, we’ve navigated difficult environments by focusing squarely on our mission. We’re approaching this situation the same way: carefully, transparently, and with the people we serve at the center of every decision. While we’re confident in our ability to ensure quality services in the long-term, we know it will take difficult decisions and hard work to address this financial situation.

The recent increase in spending is largely due to increased Medicaid waiver rates. From 2019 to 2025, the rate for direct support professionals (DSPs) increased significantly from an average of $11.12 per hour to an average of $19 per hour. This rate increase was essential to ensure people with DD could access services, that providers could hire staff, and that our DSPs were fairly paid – and HCDDS was a strong supporter of this rate increase. But this change did increase the cost of waiver services. Additional significant Medicaid rate increases are not expected.

While our costs have increased in recent years, the biggest reason we’re experiencing budgetary pressure is because our levy funding has remained flat since 2010. If you’re buying groceries, paying your electric bill, or filling your gas tank, you know that today’s dollar doesn’t stretch nearly as far as it did 16 years ago. The same is true for HCDDS. We’re running an essential public service on the same amount of levy funding we had in 2010. That flat funding simply doesn’t buy as much as it did 16 years ago. That’s the core of this challenge.

While we’re already working to reduce expenses and increase revenues, we cannot cut our way out of this situation. By 2029, our required waiver match obligation will surpass our entire levy revenue. This one mandated service will require all our levy dollars, leaving none remaining for other required and critical supports. 

HCDDS has worked to stretch every tax dollar we have as far as possible – providing incredible value to our generous and supportive homeowners in Hamilton County. While our costs have increased in recent years, the biggest reason we’re experiencing budgetary pressure is because our levy funding has remained flat since 2010. We can no longer continue to provide the same level of service or even meet our mandated financial obligations on the same flat funding.

Typically, our levy would be scheduled for the ballot in 2029. We’ve been working with the Tax Levy Review Committee (TLRC) to ensure they understand our current financial situation and to model what future funding scenarios might look like. They recognize that our revenues need to better align with our mandated expenses, and our required spending means we’ll need to go on the ballot earlier than scheduled.

In June, the TLRC presented a report to county commissioners recommending that our levy begin the process to be placed on the ballot in 2028, one year early, as a renewal with an increase. This does not guarantee that we will be placed on the ballot in 2028 or that we will receive an increase. It’s an important first step to begin the process, but the decision will ultimately be made by commissioners.

We’re focused on making adjustments that will allow our services to last long-term while minimizing the impact on those who rely on us for support. These include things like changing our business practices, aggressively pursuing additional state and federal dollars, and reviewing our ongoing contracts for potential savings. We’re committed to being transparent throughout this process and will always communicate clearly with individuals and families about any potential changes that could impact services.

Yes. Counties across Ohio face similar financial hurdles, and statewide changes will be necessary to ensure Ohio’s DD system is sustainable into the future. Like in Hamilton County, levy revenue has remained mostly flat in other counties as costs (especially to provide Medicaid waiver services) have risen sharply. Growing demand for services and a significant rate increase in the last state budget increased costs without increasing revenue.

Additional local funding is essential, but part of the solution also requires changes at the state level. We’re working with partners and other county boards to advocate at the state level. A statewide workgroup is developing potential legislative changes and will begin collecting feedback from families to shape these proposals soon. As that process begins, we’ll share more information about how you can get involved.

In 2025, HCDDS had total revenue of $100,960,790 and total expenditures of $137,691,053. You can see a breakdown of our budget in our most recent annual report.

In 2025, HCDDS had total revenue of $100,960,790. Most of our funding, about 83%, comes from a single property tax levy that must be renewed every five years for funding to continue. Another 13% of funding comes from federal sources, including billing for Medicaid services we provide and federal grants. You can see a breakdown of our budget in our most recent annual report.

In 2025, HCDDS had total expenditures of $137,691,053. The largest portion of our spending, more than 50%, pays our mandated Medicaid waiver match. Another 21% pays for direct supports for people with DD, including Service and Support Administration services, Early Intervention services, and services at Rost and Fairfax schools. You can see a breakdown of our budget in our most recent annual report.

About 3% of our budget is administration. You can see a breakdown of our budget in our most recent annual report.

Yes. Because HCDDS accesses a number of funding streams, we are audited several times per year by multiple entities. These independent audits help ensure public funds are managed responsibly. HCDDS has a strong history of successful audits, reflecting our commitment to accountability and responsible stewardship of public funds.

Each year we serve more than 10,000 people. In 2025 we served 10,462 people with developmental disabilities at every stage of life.

A sustainable future for HCDDS isn’t something we can build alone. It will take the voices of the people we support, their families, our provider partners, community members, and local and state leaders, all working in the same direction.

As a key stakeholder who understands the importance of services for people with disabilities in our local community, your voice will be essential throughout this process – both at the local and state levels. As we work toward solutions together, we’ll continue to provide information about how you can participate and share your input and perspective.  

If you still have questions, reach out to us at ContactUs@HamiltonDDSOhio.gov.