From Application to Access: Exploring Barriers and Strategies to Improve Waiver Enrollment Efficiency in the Maryland DDA

Abstract

The Maryland Department of Health (MDH) Developmental Disabilities Administration (DDA) administers Medicaid Home and Community-Based Services (HCBS) waivers, which provides critical support to individuals with intellectual and developmental disabilities (IDD). Despite efforts to reduce waiting lists and enrollment timelines, delays in waiver enrollment remain a persistent challenge, with hundreds of individuals experiencing postponed access to essential services. Internal audits highlight systemic inefficiencies, including insufficient guidance for Coordinators of Community Services (CCS), limited staffing, and missing monitoring documentation for the majority of applicants and recipients. These barriers not only create service backlogs but also threaten compliance with federal mandates and place vulnerable populations at heightened risk. This study explores the factors contributing to delays in the DDA’s waiver enrollment process and identifies strategies to streamline operations and improve service delivery. A mixed-methods research design is employed, combining quantitative analysis of administrative data including application volumes, processing timelines, staffing, and caseload sizes with qualitative insights from DDA staff collected through anonymous surveys. Survey items draw on prior work by Bogenschutz (2019) on the case management workforce and incorporate elements of the National Core Indicators (NCI) to assess staff perceptions of training, workload, organizational culture, and job clarity. Findings from this research illuminate the interplay between workforce constraints, administrative bottlenecks, and systemic inefficiencies that impact timely enrollment into DDA waiver services. The study also examines the potential role of generative artificial intelligence (AI) in reducing system redundancies, automating documentation review, and prioritizing urgent cases to enhance operational efficiency. By identifying both organizational barriers and potential technological innovations, this research aims to provide actionable recommendations for policymakers and administrators to strengthen MDH’s service delivery infrastructure, improve workforce sustainability, and expand equitable access to developmental disability services.