HCBS Integrated Settings Rule

1. HCBS Integrated Settings Rule and Transportation Impacts

2. 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 Impacts 02

4. HCBS Integrated Settings Rule and Transportation Impacts Public Transit in Iowa 03 • 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 • www.iowadot.gov/transit

5. HCBS Integrated Settings Rule and Transportation Impacts Public Transit in Iowa 04 • 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

6. HCBS Integrated Settings Rule and Transportation Impacts 3 Types of Public Transit Service 05 • 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.

7. HCBS Integrated Settings Rule and Transportation Impacts 3 Types of Public Transit Service 06 • 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.

8. HCBS Integrated Settings Rule and Transportation Impacts 3 Types of Public Transit Service 07 • 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.

9. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 08 • 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: www.dhs.iowa.gov/sites/default/files/Approved_Initial_STP_Submitted.pdf and www.dhs.iowa.gov/ime/about/initiatives/HCBS

10. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 09 • 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

11. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 10 • 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.

12. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 11 • 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.

13. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 12 • 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; www.medicaid.gov/medicaid/hcbs/guidance/index.html • 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

14. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 13 • “…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

15. HCBS Integrated Settings Rule and Transportation Impacts HCBS Integrated Settings Rule 14 • 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. HCBS Integrated Settings Rule and Transportation Impacts Public Transit work with HCBS Clients 15 • 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. HCBS Integrated Settings Rule and Transportation Impacts Public Transit work with HCBS Clients 16 • 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

18. HCBS Integrated Settings Rule and Transportation Impacts Public Transit work with HCBS Clients 17 • 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. HCBS Integrated Settings Rule and Transportation Impacts Public Transit work with HCBS Clients 18 • 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)

20. HCBS Integrated Settings Rule and Transportation Impacts Public Transit work with HCBS Clients 19 • 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

21. HCBS Integrated Settings Rule and Transportation Impacts Other Passenger Transportation Services 20 • 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. HCBS Integrated Settings Rule and Transportation Impacts Mobility Management 21 • 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

23. HCBS Integrated Settings Rule and Transportation Impacts Mobility Management 22

24. HCBS Integrated Settings Rule and Transportation Impacts Mobility Management 23 • 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 • www.iowadot.gov/iowamobilitymanagement/home

25. HCBS Integrated Settings Rule and Transportation Impacts Summary 24 • 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!