Rides for people with intellectual and developmental disabilities: day programs, group homes, and waivers

Three ways IDD rides are paid

Rides for people with intellectual and developmental disabilities (IDD) come through three doors, and the door decides who you bill. Two of the three run through Medicaid home and community-based services (HCBS) waivers, which states design within federal rules.

The line between the first and third rows is firm. CMS defines waiver transportation as an extra on top of the medical rides every state owes under 42 CFR 431.53, never a substitute for them. When a waiver participant rides to a doctor the state plan pays for, that trip belongs on state plan transportation or is charged to the state’s administrative costs, never to the waiver. For the definitions, see non-medical transportation, and for how rides get approved, waiver transportation.

Two more federal points shape these rides. Every waiver ride traces back to the person’s service plan, and unpaid rides from relatives, neighbors, friends, or community groups come first whenever someone can give one. So a paid trip exists because the planning team decided the person needs it.

When transportation is part of the day program rate

Day and residential services can carry their own transportation. CMS’s waiver application instructions tell states that if rides between home and the day habilitation site are a component of the service and paid in its rate, the service definition must say so. The same instruction appears for residential habilitation, adult day health, prevocational services, and supported employment, and residential habilitation’s core definition lists transportation among its supports.

South Carolina shows how specific this gets. Under its Community Supports Waiver, Day Activity providers furnish transportation from home to the site when the service starts before noon and from the site to home when it starts after noon, and the cost is included in the provider’s rate.

For a transportation company, a bundled service means:

• Your customer is the program, not the waiver. You bill the day program or group home at the price in your contract.
• Double billing is a compliance problem. CMS requires states to have ways to stop a ride paid inside another service’s rate from also being billed as waiver transportation.
• The contract has to do the work a rule would. Write down the schedule, how long the driver waits at the door, the rule for a rider who isn’t ready, how incidents get reported, and which parts of each service plan you will be given.

Billing waiver transportation: Ohio’s rates

Ohio’s rule for its developmental disabilities waivers, 5123-9-18 (effective January 2, 2025), is a useful model because it spells out rates and billing limits in one place. It covers the Individual Options, Level One, and Self-Empowered Life Funding waivers. A provider must be certified by the state’s developmental disabilities department and hold a Medicaid provider agreement, and it can then bill three ways: per trip, per mile, or as a bus, rail, or taxi operator at its published public fare.

Per trip. Unless the service plan says otherwise, a ride between the person’s home and a job, day program, or similar listed place is authorized per trip. The rate is paid per person, no matter how many people share the vehicle, and it depends on the county’s cost-of-doing-business category:

Per mile. Rides that do not start or end at home, such as a trip from the day program to a job or volunteer site, are authorized per mile. The per-person rate drops as more people ride, and it is higher when the vehicle is modified for the rider’s needs:

The modified rate applies to everyone in the vehicle when at least one rider’s service plan calls for a modified vehicle.

Rides to competitive jobs. Taking one person at a time to or from competitive integrated employment pays a special per-trip rate by distance. For agency providers it runs from $36.21 (0 to 15 miles, standard vehicle) to $121.29 (31 miles or more, modified vehicle).

What you cannot bill at the same time. During a per-trip ride, the rider must be in the vehicle, and you cannot also bill day services, or homemaker and personal care by the driver, for the same time. Per-mile rides allow both.

Here is an example with made-up trips at Ohio’s rates. A van carries four people from their homes to a day program in a category 6 county. Each ride is authorized per trip, so the morning run pays 4 x $28.29 = $113.16. If the same four people later ride 12 miles from the day program to a volunteer site, authorized per mile in a modified van, that leg pays 4 x 12 x $0.55 = $26.40.

Every trip needs a record that supports the claim. Ohio’s list includes the vehicle’s plate number, when the trip began and ended, where it started and finished, who drove (signature or initials), and every person on board, plus odometer or GPS miles for per-mile rides.

Drivers, vehicles, and training

IDD rules put more on the driver than most NEMT contracts do. Ohio is again specific.

Driving records and testing. Agencies get each driver’s Bureau of Motor Vehicles record no more than 14 days before the driver starts, then again at least once every three years. Six or more points disqualifies the driver, and drivers must tell the agency right away if they reach six points or lose their license. After a crash while transporting, a driver must be tested for drugs within 32 hours and alcohol within 8 hours when someone is killed, or when the driver is ticketed for a moving violation over a crash that sent someone for medical treatment off-site or left a vehicle needing a tow.

Vehicles. Any modified vehicle, and any vehicle seating five or more passengers, needs secure storage for equipment and belongings, two-way communication, and a secured fire extinguisher and first aid kit. The first driver of the day inspects and documents the lights, wipers, mirrors, horn, tires, brakes, and emergency equipment, and a modified vehicle’s wheelchair fasteners, belts, and ramp or lift before any wheelchair user boards. Once a year, the Ohio State Highway Patrol’s inspection unit or a dealer- or ASE-certified mechanic has to check it too. See wheelchair securement standards for the equipment side.

Training. Ohio counts any job where a worker may be alone with, supervise, or control a person with a developmental disability as a direct services position, which requires a criminal records check. Under its agency certification rule (5123-2-08), people in those jobs, drivers included, are direct support professionals. They must be at least 18 and hold first aid and CPR certification that included an in-person skills check. Before their first ride they complete training that includes the rights of people with developmental disabilities, putting service plans into practice, and recognizing and reporting incidents, plus training on the plan of each person they will support. More training follows within 30 days and every year. Agencies that qualify as commercial transportation operators are exempt from the first aid, CPR, and full training requirements, but their drivers still complete rights and incident training before starting, and incident training every year.

Staffing on board comes from the plan. Where a person’s plan or the program’s rules call for a support person to ride along, get that in writing before the first trip, along with anything the plan says about seating and supervision. Our driver training guide covers the general curriculum.

Behavior support plans in the vehicle

Some riders have a behavioral support strategy, and drivers must follow it exactly. Ohio’s rule, 5123-2-06, shows the kind of boundaries these plans work within.

• Restrictive measures need prior approval. Chemical, manual, and mechanical restraint, rights restrictions, and time-out are methods of last resort, used only when needed to keep people safe and with advance approval in the person’s strategy. Restraints and time-out are limited to moments when the person’s actions pose a risk of harm, and a restraint must stop as soon as that risk has passed.
• Some methods are never allowed. Prone restraint, any restraint that could restrict breathing or that causes pain, disabling a person’s communication device, and withholding meals or drinks (outside narrow medical exceptions) are prohibited.
• Normal safety equipment is not a restraint. An ordinary vehicle seat belt, an age-appropriate child safety seat, and medically necessary devices such as a wheelchair seat belt or gait belt fall outside the definition of mechanical restraint.

For a driver, the practical rule is simple: do what the plan says, never improvise a hold or a device, and call the office when a situation goes beyond the plan. Our guide to preventing rider abuse covers hiring and supervision.

Incident reporting

Incident reporting in IDD services runs on tight deadlines. A federal floor arrives on July 9, 2027, when states must run an incident management system under 42 CFR 441.302(a)(6). Each state’s definition of a critical incident must include at least:

1. Verbal, physical, sexual, psychological, or emotional abuse
2. Neglect
3. Exploitation, including financial exploitation
4. Misuse or unauthorized use of restrictive interventions or seclusion
5. A medication error that leads to a poison control call, an emergency or urgent care visit, a hospital stay, or death
6. An unexplained or unanticipated death

States must require providers to report any critical incident that happens while delivering waiver services, or because a service was not delivered, within state-set timeframes.

Ohio’s rule, 5123-17-02 (effective July 1, 2025), shows what those timeframes look like in practice:

Major unusual incidents include a missing individual, defined as a case where police have been called because the person’s whereabouts are unknown and they are believed to be at risk. When an employee is accused of physical or sexual abuse, the agency must remove that person from direct contact with anyone it serves until it decides removal is no longer needed. Keep an incident report template in every vehicle and train drivers on who to call first.

Winning group home and day program work

Group home and day program rides repeat: the same riders at the same times on most days, with drivers trained on each rider’s plan before the first trip.

1. Find out how each program is paid. If transportation is in its rate, you are a subcontractor. If not, the riders may have waiver transportation you can bill directly once you are enrolled.
2. Get enrolled and certified under your state’s developmental disabilities rules before you quote. In Ohio that means a Medicaid provider agreement and certification for non-medical transportation.
3. Price the run, not the trip. A morning route with four riders earns four per-trip payments in Ohio, while per-mile rides pay less per person as the van fills.
4. Offer consistent drivers. Training on each person’s plan happens before the first ride, so turnover costs you training hours and the program’s confidence.
5. Agree on incident handling up front. Decide who calls the county board, the family, and the program, and how fast.

Some programs will keep driving their own residents. Ohio, for example, lets providers of homemaker and personal care services transport the people they support. An outside company can fill the gaps: wheelchair riders who need a modified vehicle, larger groups, and daily day program runs the home’s own staff cannot cover. For software aimed at this work, see group home transportation software.

Keeping the daily runs on schedule

Day program riders go to the same place at the same times every week. In HealthRide, you schedule each rider’s run once and it repeats on its own through recurring trips. Each completed ride keeps its pickup and drop-off times, GPS-recorded miles, and signatures, so the details behind each program invoice are already on record.