1. and Transportation Impacts
HCBS Integrated Settings Rule
and Transportation Impacts

2. Compliance and Training Officer
HCBS Integrated Settings Rule and Transportation Impacts
Kristin Haar, Iowa DOT Office of Public Transit 01
Compliance and Training Officer
Iowa Transportation Coordination Council Chair

3. HCBS Integrated Settings Rule and Transportation Impacts02

4. 35 public transit systems, covering all 99 counties
HCBS Integrated Settings Rule and Transportation Impacts 03
Public Transit in Iowa
35 public transit systems, covering all 99 counties
Fiscal Year 2016 ridership was over 27.8 Million
24.7 Million rides provided by 19 urban systems
3.1 Million rides provided by 16 regional systems
1,600+ public transit vehicles
Funding sources include local funds, passenger fares, State Transit Assistance, and the Federal Transit Administration

5. FY 2016 Local Transit Statistics Cedar Rapids Transit
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Public Transit in Iowa
FY 2016 Local Transit Statistics
Cedar Rapids Transit
Fixed Route and ADA Complementary Paratransit Services
1.40 Million Rides
1.38 Million Revenue Miles
CorridorRides (Region 10)
Demand Response Service
212,456 Rides
1.04 Million Revenue Miles

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3 Types of Public Transit Service
Fixed Route – Provided by the 19 urban transit agencies, including Cedar Rapids Transit. This type of transit is provided with set routes, stops, and time points. No advance reservations are necessary. Service is available to the general public, including persons with disabilities.

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3 Types of Public Transit Service
ADA Complementary Paratransit – Provided by the 19 urban transit agencies in, at a minimum, ¾-mile around a fixed route. Passengers must apply, meeting ADA-qualifications to ride. Ride reservations are made the day prior to the desired trip, with the bus picking up the passenger at their location and taking them to their destination. Fares for this origin-destination service may be no more than double the regular fixed route fare.

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3 Types of Public Transit Service
Demand Response – Provided by the 16 regional transit agencies, including CorridorRides. Ride reservations are made in advance, normally 24 hours, with the bus picking up the passenger at their location and taking them to their destination. Service is available to the general public, including persons with disabilities.

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HCBS Integrated Settings Rule
Disclaimer: I work for the Iowa DOT, not Iowa Medicaid Enterprise (IME). The information presented here reflects my understanding of the Medicaid rules after consulting IME’s website and conversations with IME employees.
For more information: and

10. Medicaid HCBS = Home and Community-Based Services
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HCBS Integrated Settings Rule
Medicaid HCBS = Home and Community-Based Services
In Iowa, the HCBS program funds HCBS Habilitation Services and the seven Waiver programs: Brain Injury, Intellectual Disability, Elderly, Children’s Mental Health, Health and Disability, Physical Disability, and AIDS/HIV

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HCBS Integrated Settings Rule
Federal regulations became effective on March 17, 2014, defining the settings in which it is permissible for states to pay for Medicaid HCBS.
The purpose of these regulations is to ensure that individuals receive Medicaid HCBS in settings that are integrated in and support full access to the greater community.
Includes opportunities to seek employment and work in competitive and integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree as individuals who do not receive HCBS.

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HCBS Integrated Settings Rule
The regulations also aim to ensure that individuals have a free choice of where they live and who provides their services, as well as ensuring that individual rights are not restricted.
While Medicaid HCBS has never been allowed in institutional settings, these new regulations clarify that HCBS will not be allowed in settings that have the qualities of an institution.

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HCBS Integrated Settings Rule
At the time the federal regulations were enacted, states were given five years to transition to compliance – March 17, 2019
This spring, the federal Centers for Medicare and Medicaid Services (CMS) extended that deadline to March 17, 2022;
However, Iowa has not amended its state plan to reflect that extended deadline and is still on track to meet the federal transition requirements by 2019

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HCBS Integrated Settings Rule
“…HCBS will not be allowed in settings that have the qualities of an institution.”
What might this affect?
Sheltered workshops
Group homes
If service provider proposes to keep a sheltered workshop, group home, or other facility currently funded with HCBS money after March 2019, IME will evaluate to determine if it is integrated in the community

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HCBS Integrated Settings Rule
Positives:
Entire community benefits by living near and working with persons with disabilities
HCBS Waiver recipients benefit by working and living in their chosen community

16. Current, common example of public transit service to HCBS clients:
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Public Transit work with HCBS Clients
Current, common example of public transit service to HCBS clients:
9 a.m. Bus stops at several group homes and picks up 18 people, filling to capacity, and transports to a sheltered workshop for the day’s work and activities
3 p.m. Bus returns to sheltered workshop and picks up same 18 people and returns them to their group homes
Typically Monday – Friday service

17. Future, possible example of public transit service to HCBS clients:
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Public Transit work with HCBS Clients
Future, possible example of public transit service to HCBS clients:
6 a.m. Bus stops at apartment building and picks up 2 people and transports to a local employer for the day’s work shift
8 a.m. Bus returns to local employer to transport the 2 clients to day health/habilitation facility
3 p.m. Bus returns to day health facility to transport the 2 clients to their apartment building

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Public Transit work with HCBS Clients
Examples were Monday – Friday. However, work shifts will likely include evenings, overnights, and weekends when public transit isn’t typically available.
Current example filled the bus to capacity with one driver. However, in the future example those 18 people will possibly all have different residences, workplaces, and shift times.

19. Public Transit Challenges:
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Public Transit work with HCBS Clients
Public Transit Challenges:
Current service hours and days may not match those times when transportation is needed for HCBS clients (operating funds already tight)
Current vehicle sizes may be too large for the more individualized transportation needs of the HCBS clients (capital funds for vehicles limited)
If more trips in smaller vehicles are required, finding the quantity of drivers needed will prove difficult in many areas of the state (driver shortages are a current problem)

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Public Transit work with HCBS Clients
Public Transit must be included in the early conversations, planning what will happen when a sheltered workshop closes or when group home residents move into individual apartments around town
Transportation cannot be an afterthought in the decision-making process
New service hours, days, vehicles, and drivers all require advance planning on the part of the public transit system

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Other Passenger Transportation Services
It’s not just about public transit, other partners and options must be considered:
Taxis, intercity bus service, human service organizations, non-emergency medical transportation, ridesharing companies, and volunteer transportation can all play a role

22. The transportation solution may not come from just one source
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Mobility Management
With all the options that may be available, it can be a very overwhelming to know how to best get from point A to point Z
The transportation solution may not come from just one source
Several communities and regions throughout the state have hired mobility coordinators to help with just those issues

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Mobility Management

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Mobility Management
Mobility management is person-centered, assisting with the whole trip, using as many modes of transportation necessary, not just public transit
Mobility managers assist individuals and groups with travel training, transit presentations, and finding the best options for making a trip

25. Expanded partnerships
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Summary
Especially for rural, demand-responsive public transit systems, the HCBS Integrated Settings Rule will have a dramatic impact on service offerings
Public transit likely cannot provide every trip needed, on every day and time desired – other transportation partners must be sought out
Transportation must be part of the conversation from the beginning, not as an afterthought
This is an opportunity
Expanded services
Expanded partnerships

26. Questions?
Comments?
Thank you!