Instructions for Full Survey

Transcription

1 WYOMING DEPARTMENT OF HEALTH BEHAVIORAL HEALTH DIVISION Provider Cost & Wage Survey Anticipated release date: September 5, 2017 Due date: October 10, 2017 Comprehensive, Supports and Acquired Brain Injury Medicaid Waivers Instructions for Full Survey

2 Survey Overview Do you have a question concerning the Provider Cost and Wage Survey? Navigant will post a list of frequently asked questions to the survey website, found at If the answer to your question is not on that list, you may also Navigant at wyomingbhd@navigant.com or call Navigant staff will respond to you as soon as possible. Note: It is important to read the instructions in their entirety before completing the survey. Wyoming Statute (g) requires the Wyoming Medicaid Behavioral Health Division ( The Division ) to rebase reimbursement rates for the Comprehensive, Supports and Acquired Brain Injury (ABI) Waivers every two to four years (referred to collectively in this survey as the Developmental Disability (DD)/ABI waivers). As part of the rate rebasing process, the Division is conducting a provider cost and wage survey to analyze actual provider costs and revise the assumptions used for the rate models. Completion of this survey is your opportunity to inform the Division about your operational costs. This document contains instructions to assist providers in completing the full version of the cost and wage survey ( the survey ). A provider is defined as a controlling entity, agency or corporate organization that provides Home and Community Based Services (HCBS) and generally possesses a Primary National Provider Identification (NPI) Number. This full survey should be completed by large providers, defined as providers who received $1,000,000 or more in Medicaid payments for Comprehensive, Supports and ABI waiver services delivered during State Fiscal Year (SFY) In regards to other providers: Providers earning less than $1,000,000 are asked to fill out a separate wage survey, but are welcome to fill out the full cost and wage survey if they are able. Providers that do not designate wage rates do not need to complete a survey; these are providers that do not have a business tax identification number, or used their social security number as a business tax identification number. Case management agencies have a separate case management survey that they should complete. Navigant 9/5/2017 Page 1

3 Survey Overview The survey website provides additional copies of the surveys and corresponding instructions along with a list of frequently asked questions PLEASE NOTE THAT INDIVIDUALS COMPLETING THIS SURVEY MUST HAVE A WORKING KNOWLEDGE OF PROVIDER OPERATIONS, AND A THOROUGH UNDERSTANDING OF THE ACCOUNTING RECORDS OF THE ORGANIZATION. Overview The individual schedules included in this survey provide a mechanism for translating costs and other information reported in your accounting and other operating records into a consistently reported format that can be easily analyzed for purposes of this study. The instructions explain the information that we are seeking on each line item. Please complete the survey exactly as requested. Note that some questions of this survey may pertain to services that you do not provide or personnel you do not employ. Please skip such questions. We request you provide data as completely and accurately as possible for the services that you offer and the personnel you employ. Survey Reporting Time Schedule Please submit your completed survey to Navigant Consulting by Tuesday, October 10,, If you are a CARF provider, please also submit either by (wyomingbhd@navigant.com) or mail (see mailing address below) a copy of your most recent independent auditor s financial audit or review report that corresponds with the survey reporting period. Reporting Period The reporting period for this survey should be the provider s most recently completed fiscal year. Therefore, if your agency s fiscal year follows the calendar year, you would report for the period ending December 31, If you report data on the State s fiscal year, you would report for the period ending June 30, Review of Surveys The Division or its agents may perform a desk review on surveys to determine if the financial and statistical information submitted conforms to applicable rules and instructions. How to Download And Submit The Survey If you did not receive the survey via , the survey is available in Excel and PDF formats on the survey website The survey is not designed to Navigant 9/5/2017 Page 2

4 Survey Overview be completed on the website; instead, we request you download a copy of the survey on to your computer and complete it in Excel and, when complete, it to wyomingbhd@navigant.com. If you do not have Excel capabilities, you may choose to complete a printed paper copy of the PDF based survey and then either scan and it to the address above or mail it to Manhad Mohomed (address below). Please ensure that paper based surveys are easily legible. Manhad Mohomed, Consultant Navigant Consulting, Inc. 150 North Riverside Plaza, Suite 2100 Chicago, IL If your survey is not properly completed, the Division or Navigant Consulting, Inc. staff may contact you for clarification. Resubmission of Surveys If you have already submitted your completed survey, but wish to submit a revised version for whatever reason (correction of error, more current data, etc.), you may do so by sending a revised version to the abovementioned or mail address. At the close date of the survey submission process, we will identify the survey file most recently received from organization and discard any versions submitted previously. The latest version we receive from your organization will be the version used for purposes of the rate rebasing process. Independent Accountant s Report As mentioned above, if you are a CARF provider, you must also submit a copy of your most recent independent accountant s financial audit or review report that corresponds with the HCBS survey reporting period. You may submit such documents through either the survey website, (see address above) or mail (see mailing address above). How to Complete this Survey if Your Organization has Multiple Sites If your organization has multiple provider sites and collects cost data individually for each site, you may choose to submit information for each site using separate surveys. Because geography and size may have a significant impact on provider costs, we recommend you complete multiple surveys if: 1. Your sites are located in different regions (i.e., urban, semi rural and rural), OR 2. Your sites have different sized service areas (i.e., Site A serves participants within a 25 mile radius while Site B primarily serves participants living within miles), OR 3. Due to other reasons, waiver related costs vary considerably by site Navigant 9/5/2017 Page 3

5 Survey Overview Specific Instructions, by Worksheet The following table provides a brief description of each of the Worksheets included in the survey. All applicable forms must be completed. Table 1: Cost and Wage Survey Worksheets Worksheet A. Provider Information B. Services C. Provider Costs D. Wages E. Turnover F. Health Insurance Benefits G. Retirement Benefits H. Case Management Questions Description General identifying information about the provider, including locations, service area, revenues and total staffing Services your organization delivers to Comprehensive, Supports and ABI waiver participants Total Fiscal Year (FY) costs incurred, including employee salaries and wages, program support costs, general & administrative costs and employee related costs Total direct care employee wages, hours and benefits incurred by the provider for services, broken down by employee type Total full and part time employees, unfilled positions, turnover and reasons for turnover Health insurance benefit costs and details Information on retirement benefits, if any, offered by your organization by your employee Information about case management clients, if applicable I. Error Check Check of potential errors in survey Specific instructions for each of the above Worksheets are provided on the following pages. Navigant 9/5/2017 Page 4

6 Worksheet A: Provider Information WORKSHEET A: PROVIDER INFORMATION The purpose of this worksheet is to identify the provider organization and the survey respondent and collect information on the provider sites, including number of participants served and service radius. Provider Identification Line 1: Provider Name. Enter provider s full name, as submitted on claims billed under the specific Medicaid provider number for which you are responding for this survey. Line 2: Primary NPI Number. Enter the primary NPI Number for the provider organization for which you will be submitting data, which is in the provider notification letter you received about this survey. If you are a provider that uses several NPI Numbers for billing purposes, please submit survey data related to all services provided by your controlling agency on a single survey form and list the Primary NPI Number only on Line 2. Line 3: City. Enter city associated with the Medicaid provider number Line 4: County. Enter county associated with the Medicaid provider number Line 5: CARF Certification Status: Enter whether you have CARF certification or not. Line 6: Provider Fiscal Year Beginning: Enter start date (MM/DD/YY) of the provider s fiscal year represented in survey. This date should be no earlier than January 1, 2016 Line 7: Provider Fiscal Year Ending. Enter end date (MM/DD/YY) of provider s fiscal year represented in survey. This date should be no later than June 30, 2017 Contact Information Line 8: Contact Person. Enter name of person responsible for completing this survey. Line 9: Title. Enter title of person responsible for completing this survey. Line 10: Phone Number. Enter phone number (XXX XXX XXXX) of person responsible for completing this survey. Line 11: Address. Enter address of person responsible for completing this survey. Navigant 9/5/2017 Page 5

7 Worksheet A: Provider Information Provider Site(s) Note: If you operate more than four sites, choose four that represent the range of your costs. Line 12: City. Enter the city where Provider Site 1 is located. Line 13: County. Enter the county where Provider Site 1 is located. Line 14: Number of Waiver Participants Served. Enter the total number of waiver participants served during the provider fiscal year reported in Line 7. All other individuals served by you or your organization should be excluded from this calculation (e.g., individuals only receiving TCM and not in the Comprehensive, Supports or ABI waiver programs). Line 15: Percent of Clients That Live Within. Of the waiver participants reported in Line 14, indicate the percentage who live within 0 25 miles, miles, and greater than 50 miles. An estimated percentage should be calculated by dividing the number of participants living within each service radius category by the total number of waiver participants served at the site. Lines 16 19: Provider Site 2. If your organization serves waiver participants at a second site, please fill in the items defined in Lines as described above. Lines 20 23: Provider Site 3. If your organization serves waiver participants at a third site ( Provider Site 3 ), please fill in the items defined in Lines as described above. Lines 24 27: Provider Site 4. If your organization serves waiver participants at a fourth site ( Site 4 ), please fill in the items defined in Lines as described above. Line 28: Are you completing this survey for a particular site? If your organization has multiple provider sites and collects cost data individually for each site, you may choose to submit to information for each site using separate surveys. Line 29: If yes, please indicate the relevant site. If the remainder of the survey pertains to a unique site, indicate which site. Provider Staffing Note: For Lines 30 and 31, please report for your entire organization. If you operate multiple sites, combine and enter the total number of employees from all your sites. Navigant 9/5/2017 Page 6

8 Worksheet A: Provider Information Line 30: Total Number of Full Time Employees. Enter the total number of full time employees who were employed at the end of the provider fiscal year reported in Line 7. Full time employees are defined as employees working 30 hours or more in an average week or 130 hours or more in an average month. Line 31: Total Number of Part Time Employees. Enter the total number of part time employees who were employed at the end of the provider fiscal year reported in Line 7. Part time employees are defined as employees working fewer than 30 hours in an average week or 130 hours in an average month. Navigant 9/5/2017 Page 7

9 Worksheet B: Services WORKSHEET B: SERVICES This worksheet is used to identify the approved waiver services your organization provided to waiver participants in the provider fiscal year entered on Worksheet A. Please check all that apply. Note: If you are completing separate surveys for each site, please check only those services that you provide at the respective site for which you are responding. Navigant 9/5/2017 Page 8

10 Worksheet C: Provider Costs WORKSHEET C: PROVIDER COSTS The purpose of this worksheet is to report the total costs of the Provider and to determine the net waiver program portion of total costs. Column Descriptions Columns 1 and 2: Cost Centers and Uniform Chart of Accounts Code Each cost center line represents a particular type of expenditure. The cost center line is described in Column 1. Cost centers are classified into six major groups: Salaries and Wages Employee Taxes, Insurance and Benefits Contracted Services Non Payroll Administration Expenses Non Payroll Program Support Expenses Facility, Vehicle and Equipment Related Expenses Please see the Lines Descriptions section below for further discussion of each cost center under the six major groupings. The cost center lines are designed to reflect accounts listed in the Uniform Chart of Accounts for HCBS providers, which was developed through the Division s previous cost survey process. This Uniform Chart of Accounts can be found at the project website at The corresponding account code from the Uniform Chart of Accounts for each cost center line is listed in Column 2. Column 3: All Costs from Provider General Ledger Enter all costs of the Provider in Column 3 by cost center. The total expenses reported on Line 97 of Column 3 must be equal to the total expenses reported in the Provider s general ledger. For costs recorded in the Provider s general ledger that do not match the listed cost center descriptions, lines are provided for other expenses within each of the major cost groups. Providers who utilize the other expense lines must enter in a description of the expense in the line. The description must include explanations of the types of costs being reported and the amounts of any such costs. Navigant 9/5/2017 Page 9

11 Worksheet C: Provider Costs Columns 4 and 5: Non Waiver Program and Waiver Program Costs Enter non waiver program costs in Column 4. Waiver program costs in Column 5 equal Column 3 less Column 4. Non waiver program costs include the costs of goods and services that are related to the services not covered by Wyoming s Comprehensive, Supports and ABI Waiver Programs. The following are examples of non waiver program costs, although this list is not allinclusive: Costs related to educational services, including the costs of school employees and supplies associated with school contracts or for programs of the Department of Education. Costs of goods and services related to the production of products and services, such as in a sheltered workshop or recycling center, restaurant or cafe, car wash, etc., including the salaries and wages paid to participants in a work setting. Costs related to services paid by the State of Wyoming or other governmental agency outside of Wyoming s Comprehensive, Supports and ABI Waiver Programs, such as the salaries and wages associated with physicians, psychiatrists and therapists for providing services that are paid by Medicaid as State Plan services or through Medicare. Non waiver Program Room and Board Costs In addition, costs related to room and board for participants, as well as facility maintenance, upkeep and improvement related to residential program services are neither covered by Wyoming s Comprehensive, Supports and ABI Waiver Programs nor are they program costs, and therefore should be reported in the non waiver program cost column 1. Costs can be considered waiver program costs to the extent that they relate to the acquisition, retention or improvement of daily living skills, such as personal grooming and cleanliness, bed making and household chores, eating and the preparation of food and the social and adaptive skills necessary to enable the individual to reside in a non institutional setting. However, the costs associated with housing (rent, interest or mortgage expenses, utilities, property maintenance, etc.) and food or meals are not covered, and should be reported as non waiver program costs in Column 4. 1 In accordance with 42 CFR (a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant. Navigant 9/5/2017 Page 10

12 Worksheet C: Provider Costs If a provider is unable to specifically identify non covered room and board costs for reporting purposes, a reasonable estimation of these costs may be determined based on the amount of funding that should be collected by the provider from the participant or participant sources intended to cover daily living expenses (except for personal allowance amounts), such as Federal SSI or other State supplemental amounts. To the extent that non waiver program costs and program costs are not easily distinguishable in your provider accounting books and records, it may be necessary to make reasonable allocations between these two categories of costs. For example, salaries and wages may be allocated based on an estimate of actual time spent by employees between program and non waiver program activities, and facility related costs (rent, interest expense, utilities, property maintenance, etc.) may be allocated based on reasonable estimates of property square footage used for program and non waiver program services. Other costs, such as administrative supplies, can be allocated based on reasonable estimates of their use. Program costs are defined as the reasonable costs necessary to provide services to persons with developmental disabilities or acquired brain injury, and directly related to the Waiver programs. Federal guidance on reasonable costs can be found in PRM 15, Section 2103, which states the following: The prudent and cost conscious buyer not only refuses to pay more than the going price for an item or service, he/she also seeks to economize by minimizing cost. This is especially so when the buyer is an institution or organization which makes bulk purchases and can, therefore, often gain discounts because of the size of its purchases. In addition, bulk purchase of items or services often gives the buyer leverage in bargaining with suppliers for other items or services. Another way to minimize cost is to obtain free replacements or reduced charges under warranties for medical devices. Any alert and cost conscious buyer seeks such advantages, and it is expected that Medicare providers of services will also seek them. While this federal guidance does not apply specifically to waiver services reimbursed by states, it is consistent with how the Division is requesting providers to report their costs in this survey. In other words, the Division is requesting that providers report only the reasonable and necessary costs of providing the specified services. In principal, the term reasonable relates to the prudent and cost conscious buyer concept that purchasers of services will seek to economize and minimize costs whenever possible. The term necessary relates to the necessity of the service. To be necessary, it must be a required element for providing care to participants as specified by the approved federal waivers. Navigant 9/5/2017 Page 11

13 Worksheet C: Provider Costs The Social Security Act section 1861(v)(1)(A) provides additional guidance, stating that reasonable costs must be the following: Cost actually incurred Necessary in the efficient delivery of needed health services Determined in accordance with regulations establishing the methods to be used and the items to be included The Division requests that you follow these federal guidelines as well. Please also refer to the document titled Program Cost Guidelines that discusses the concept of program costs and gives examples of non program costs at the survey website at Column 6: Additional Information In this column, verify that costs in Column 5 do not contain room and board costs by checking the appropriate checkbox as requested. For Lines 39 41, please check the appropriate box if the costs for vision, dental, and/or life insurance are included in Line 38 (health insurance) because they cannot be broken out separately. Line Descriptions The lines in the survey have been revised to reflect the Uniform Chart of Accounts. Please see the document titled Uniform Chart of Accounts Account Descriptions for detailed definitions of each account, available online at We understand that you may incur certain costs on a non recurring basis. In other words, you may have incurred costs in the current year for which the benefit may span more than the current year. Conversely, you may have incurred costs in previous years that benefit the current year, but are not reflected in your current general ledger costs. If you have one time cost in this year s expenses or incur costs on a regular basis that are not in the current general ledger (i.e., a multi year license that is expensed when it is renewed), please provide that information in separate documentation so that it may be considered as part of the survey process. Such information can be provided via the address shown on page 1 of these instructions (please include your NPI Number in the body of the ). Salaries and Wages, Lines 1 through 32 Lines 1 through 32 capture total salaries and wages paid and accrued by employee category. Do not include fees associated with contracted services staff (these costs should be included Navigant 9/5/2017 Page 12

14 Worksheet C: Provider Costs in the Contracted Services section of the survey). For employees who perform multiple functions (administration, program support, etc.), gross salaries and wages must be allocated to each of the appropriate cost categories. Program Employee Salaries and Wages, Lines 1 through 14 These cost center lines capture program employee total gross salaries and wages paid and accrued, including bonuses, by employee category. Program Employee Salaries and Wages are defined as costs associated with employees who provide direct hands on support for participants. This includes Direct Care Workers, Trainers and Supervisors, Case Managers, Job Coaches and Vocational Trainers, Dieticians, Nurses, Psychiatrists, Psychologists and Therapists. Enter amounts, by employee category, on Lines 1 through 12. Enter amounts for other program employees on Line 13; and a description of the expense in Column 1. The survey will automatically sum Lines 1 through 13 on Line 14. Do not enter data into this line. Program Support Employee Salaries and Wages, Line 15 These cost center lines capture program support employee total gross salaries and wages, including bonuses, by employee category. Program Support Employee Salaries and Wages are defined as costs associated with employees who provide support of participant programs, such as housekeeping, laundry, cooking, program coordinators and quality assurance and data analysts. Program support employees may be in contact with participants, but they do not provide direct hands on participant care. Enter program support salaries and wages, by category, on Line 15. Maintenance Employee Salaries and Wages, Lines 16 through 18 These cost center lines capture maintenance employee total gross salaries and wages, including bonuses, by employee category. Maintenance Employee Salaries and Wages are defined as costs associated with employees who repair and maintain vehicles, equipment, buildings and property. Enter vehicle maintenance employee salaries and wages on Line 16. Enter all other maintenance employee salaries and wages expenses on Line 17. Navigant 9/5/2017 Page 13

15 Worksheet C: Provider Costs The survey will automatically sum Lines 16 and 17 on Line 18; as such, do not enter data into this line. Administration Employee Salaries and Wages, Lines 19 through 27 These cost center lines capture administration employee total gross salaries and wages, including bonuses, by employee category, on Lines 19 through 27. Administration Employee Salaries and Wages are defined as costs associated with employees who provide management, accounting, information technology, and human resource services. Enter administration employee salaries and wages by category, on Lines 19 through 27. Only include administration costs incurred at the provider or local level. If administrative services are provided at a central corporate office outside of the provider s principal place of business, then enter the allocated portion of administrative employee salaries and wages applicable to the local level (not entered elsewhere in this section) in Line 24 ( Central Office Administration Staff ). Enter other administration employee salaries and wages on Line 26. Enter a description of the expenses in Column 1. The survey will automatically sum Lines 19 through 26 on Line 27. Do not enter data into this line. Client and Other Salaries and Wages, Lines 28 through 31 Enter participant total gross salaries and wages, including bonuses, on Line 28. Enter the value of donated services on Line 29. Enter other salaries and wages on Line 30. Enter a description of the expenses in Column 1. The survey will automatically sum Lines 28 through 30 on Line 31. Do not enter data into this line. The survey will automatically sum Lines 14, 18, 27, and 31 on Line 32, Total Salaries and Wages; as such, do not enter data into this line. Navigant 9/5/2017 Page 14

16 Worksheet C: Provider Costs Employee Taxes, Insurance and Benefits, Lines 33 through 49 Lines 33 through 49 capture costs incurred by the Provider related to employee payroll taxes, insurance and benefits. Only the portion of the employee benefits and payroll taxes paid and accrued by the provider must be reported on these lines. Please also include any non wage compensation (e.g., monetary and non monetary gifts). Do not include costs which are paid and accrued by withholding a portion of the employee s salary or wages (these costs should be included in the appropriate Salaries and Wages cost center lines). Employee Payroll Taxes, Lines 33 through 37 These cost center lines capture the employer s portion of any FICA, FUI, SUI, and other payroll related taxes. Enter amounts, by category, on Lines 33 through 36. Enter the total amount spent on the employer s portion of premiums paid and accrued for the state workers compensation fund or other workers compensation insurance and other payroll taxes plan on Lines 36. If a Provider is self insured, only include the cost of actual claims paid or accrued. The survey will automatically sum Lines 33 through 36 on Line 37; do not enter data into this line. Employee Insurance, Lines 38 through 45 These cost center lines capture the employer s portion of any costs related to employee health insurance, vision insurance, dental insurance, life insurance, disability insurance and participant fringe benefits. Enter amounts, by category, on Lines 38 through 44. Amounts reported on Lines 43 and 44 must be accompanied by a description of reported costs. The survey will automatically enter the sum of Lines 38 through 44 on Line 45; therefore, do not enter data into Line 45. Employee Other Benefits, Lines 46 through 48 These cost center lines capture the employer s costs related to retirement and any other employee benefits not recorded elsewhere in rows 46 through 48. Navigant 9/5/2017 Page 15

17 Worksheet C: Provider Costs Enter the employer s portion of any costs related to employee retirement programs on Line 46. These costs could include employer contributions to pension plans, employer contributions to 401k plans, or other retirement related programs. Enter any other benefits costs not reported on Line 46 on Line 47. Enter a description of the costs in Column 1. The survey will automatically sum Lines 46 and 47 on Line 48. Do not enter data into this line. The survey will automatically enter the sum of Lines 37, 45 and 48 on Line 49, Total Employee Taxes, Insurance and Benefits. Do not enter data into this line. Contracted Services, Lines 50 through 66 Lines 50 through 66 capture expenditures for contracted services, by type of contracted service. Amounts entered must be for contracted services only, and must exclude any amounts paid and accrued to employees of the Provider. Contracted Program Services, Lines 50 through 63 These cost center lines capture expenditures for contracted program services, by type of contracted service. Enter amounts, by type of contracted service, on Lines 50 through 61. Enter other contracted program services on Line 62. Enter a description of the expense in Column 1. The survey will automatically sum Lines 50 through 62 on Line 63. Do not enter data into this line. Contracted Maintenance Services, Line 64 This cost center line captures expenditures for contracted maintenance services. Enter total amount spent on contracted maintenance services on line 64. Contracted Administration Services, Lines 65 These cost center lines capture expenditures for contracted administration services Enter total amount spent on contracted administration services on line 65. The survey will automatically sum Lines 63, 64 and 65 on Line 66, Total Contracted Services. Do not enter data into this line. Navigant 9/5/2017 Page 16

18 Worksheet C: Provider Costs Non Payroll Administration Expenses, Lines 67 through 86 Lines 67 through 86 capture administration expenses not relating to payroll. Only the portion paid and accrued by the provider must be reported on these lines. Administration Expenses, Lines 67 through 76 These cost center lines capture expenditures for non payroll related provider administrative services, including office supplies, postage, membership dues and information technology expenses. Do not report the costs associated with contracted services (these costs must be reported in the appropriate contracted services cost center lines). Enter all administration expenses, by type of administration expense, on Lines 67 through 74. Enter Other Administrative Expenses on Line 75. Enter a detailed description of the expense(s) in Column 1. The survey will automatically sum Lines 67 through 75 on Line 76; as such, do not enter data into this line. Licenses/Taxes, Line 77 These cost center lines capture non payroll taxes incurred by the provider. Enter amounts for license and taxes, such as ad valorem property taxes and vehicle license and registration expenses on Line 77. Liability and Other Insurance, Lines 78 through 80 These cost center lines capture expenditures for vehicle and other provider insurance. Enter vehicle related insurance costs on Line 78. Enter insurance costs for all other types of insurance on Line 79, including, for example, general liability, directors and officers, property, and malpractice insurance. The survey will automatically sum Lines 78 through 79 on Line 80; as such, do not enter data into this line. Navigant 9/5/2017 Page 17

19 Worksheet C: Provider Costs Non Payroll Related Personnel Expenses, Lines 81 through 85 These cost center lines capture all non payroll expenditures for employees, including costs relating to hiring and training of new workers. Enter the non personnel costs of background check and drug testing on Line 81. Enter the non personnel costs of recruitment on Line 82. Enter the non personnel costs of training related to the provision of consumer care on Line 83. Do not report the payroll costs associated with providing or participating in training (these costs must be reported in the appropriate salaries and wages category). Enter other non payroll personnel expenses on Line 84. Enter a description of the expenses in Column 1. The survey will automatically sum Lines 81 through 84 on Line 85. Do not enter data into this line. The survey will automatically sum Lines 76, 77, 80 and 85 on Line 86, Total Non Payroll Administration Expenses. Do not enter data into this line. Non Payroll Program Support Expenses, Lines 87 through 91 Lines 87 through 91 capture non payroll expenditures made for the support of participant programs. Supplies, Line 87 These cost center lines capture expenditures for materials used in participant care or programs support services. Transportation, Lines 88 through 90 These cost center lines capture the costs of transportation, including transportation reimbursements made to program staff. Do not report the costs associated with vehicle purchases or leases, licenses or insurance (these costs should be reported in the appropriate facility/vehicle/equipment expenses, administrative expenses, or employee taxes, insurance and benefits cost center lines). Enter service related transportation expenses on Line 88. Transportation costs include fuel expenses and mileage reimbursements made to program staff for transportation Navigant 9/5/2017 Page 18

20 Worksheet C: Provider Costs directly relating to client services. A client does not have to be inside of the vehicle for the transportation to be service related (i.e., a program employee traveling to see a client). Vehicle maintenance and repair expenses should be included in the appropriate maintenance line. Providers must maintain detailed mileage records to support the reported service related expenses. Enter non service related transportation expenses on Line 89. These are costs relating to gas, rental cars, airfares, meals and lodging while traveling to out of town offices, institutions, and conferences for administrative purposes. This line includes travel by program employees for training purposes. The survey will automatically sum Lines 88 and 89 on Line 90. Do not enter data into this line. The survey will automatically sum Lines 87 and 90 on Line 91, Total Non Payroll Program Support Expenses. Do not enter data into this line. Facility, Vehicle and Equipment Related Expenses, Lines 92 through 96 Lines 92 through 96 capture non payroll related facility, vehicle and equipment expenses. Do not include costs associated with contracted services (these costs should be reported in the appropriate contracted cost center lines). Rentals/Property, Line 92 These cost center lines capture rental and property expenses related to facilities, vehicles and equipment, by category. If building rental or lease agreements are with related parties, costs exceeding the cost to the related party should be considered non waiver program, and entered into Column 4. Enter rental and property expenses, by type of expense, on Lines 92. Maintenance and Repairs, Line 93 These cost center lines capture all non payroll maintenance and repair expenses related to facilities, vehicles and equipment, by category. Enter maintenance repair expenses, by type of expense, on Line 93 Navigant 9/5/2017 Page 19

21 Worksheet C: Provider Costs Depreciation and Amortization, Line 94 These cost center lines capture depreciation for provider owned facilities, vehicles and equipment. Providers must submit, along with the survey, a description of their capitalization policy and threshold amount(s). A capitalization threshold is a cost under which an asset should not be depreciated. If an asset has a useful life of at least two years and a historical cost of at least $5,000, its cost must be capitalized. Assets under the set threshold amount should be expensed in the year acquired. A provider may set a lower capitalization threshold if it does not materially affect reported costs. Utilities, Line 95 These cost center lines capture expenses related to utilities and disposal services. The survey will automatically sum Lines 92, 93, 94 and 95 on Line 96, Total Facility, Vehicle and Equipment Related Expenses. Do not enter data into this line. The survey will automatically sum Lines 32, 49, 66, 86, 91 and 96 on Line 97, Grand Totals. Do not enter data into this line. Provider Revenues Note: If you operate multiple sites, enter total revenues earned across all your sites. Line 98: Total BHD Waiver Revenues (Comprehensive, Supports, ABI). Total revenues, as recorded in the Provider s general ledger, earned from Medicaid payments for Comprehensive, Supports and ABI waiver services delivered during the provider fiscal year reported on this worksheet. Line 99: Total Targeted Case Management (TCM) Revenues, if Applicable. If your agency employs case managers who provide targeted case management (TCM) services, enter the total revenues, as recorded in the Provider s general ledger, earned from such TCM services. Line 100: Total Revenues from Other Services, if Applicable. Total revenues, as recorded in the Provider s general ledger, earned from other Medicaid and non Medicaid sources during the provider fiscal year reported on this worksheet, including ay revenues earned from provider owned businesses. Line 101: Total Revenues. Automatically Calculated. Total revenues for the provider fiscal year reported on this worksheet as recorded in the Provider s general ledger. Navigant 9/5/2017 Page 20

22 Worksheet C: Provider Costs Additional Question Line 102: Please explain if your agency incurred partial year expenses in the provider fiscal year reported on this worksheet for any services, operations, or facilities. If your agency incurred partial year costs related to changes in services (new or discontinued), operations or facilities during the provider fiscal year reported on this worksheet, please describe them in the text box below. Line 103: Has your agency experienced significant changes in costs since the fiscal year period for which you are reporting data? If so, please explain. If your agency has experienced significant changes in costs since the conclusion of the fiscal year period for which you have reported on this worksheet, please describe them in the text box below. Navigant 9/5/2017 Page 21

23 Worksheet D: Wages WORKSHEET D: PROGRAM EMPLOYEE WAGES This worksheet captures wage and hour data for program (direct care) employees as of August 31, Line Description The lines in this Worksheet represent different employee types. Program Employee Salaries and Wages, Lines 1 through 15 Lines 1 through 15 capture employee hourly wages paid to employees who provided direct hands on support for waiver participants. If your employees are paid on a salary basis, you can calculate hourly wages by dividing the annual salary by 2,080 (the number of working hours in a year based on a 40 hour work week), or for part time salaried positions, a reasonable estimate of the number of hours worked over the course of a year. If your employees regularly work overtime, you may divide the salary by more than 2,080 as appropriate. Enter wage information for each employee type on lines 1 through 14 (the same employee types as listed in Worksheet C). If there are Other Program Employees that you identified on Worksheet C, please enter the relevant wages for these employees in aggregate on line 15. Column Description Please fill out Columns 1 12, described below, for each of the employee types you employ. Regular Wages (excludes bonuses and overtime pay) Hourly Wage: Column 1: Average Hourly Wage. Enter the average hourly regular wage paid among all employees for each employee type. Column 2: Lowest Hourly Wage. Enter the lowest hourly wage rate (actual, not average) among all employees for each employee type. Column 3: Highest Hourly Wage. Enter the highest hourly wage rate (actual, not average) among all employees for each employee type. Navigant 9/5/2017 Page 22

24 Worksheet D: Wages Raises: Average Percent Increase in Wages To convert employee raises from a dollar amount to a percentage increase in wages, please divide the average hourly raise amount by the average hourly wage prior to the raise and payroll deductions. Column 4: Average Percent Increase from 2014 to Enter the average percentage wage increase from 2014 to 2015 you gave to each employee type, if any. Column 5: Average Percent Increase from 2015 to Enter the average percentage wage increase from 2015 to 2016 you gave to each employee type, if any. Column 6: Average Percent Increase from 2016 to Enter the average percentage wage increase from 2016 to 2017 you gave to each employee type, if any. Bonuses: Average Annual Percent of Salary and Wages If you provide bonuses, please divide the average total annual bonus amount by the average annual salary/wages prior to payroll deductions for each employee type to calculate an average percentage. Column 7: Average percent bonus in Enter the average percent bonus in 2014 given to each employee type, if any. Column 8: Average percent bonus in Enter the average percent bonus in 2015 given to each employee type, if any. Column 9: Average percent bonus in Enter the average percent bonus in 2016 given to each employee type, if any. Paid Time Off and Training Hours Please fill out Columns 10 11, described below, for each of the employee types you employ. Column 10: Paid Time Off: Allowed Annual Hours per FTE including Vacation, Holiday, and Sick Time. Enter the total number of hours of paid time off you allow for each employee type, including vacation, holiday, sick, and other time off, on an annual basis. Column 11: Average Annual Paid Training. Enter the total number of hours of paid training time you allow for each employee type on an annual basis. Do not include travel time. Navigant 9/5/2017 Page 23

25 Worksheet D: Wages Unfilled Positions as Of 8/31/2017: Column 12: Number of Unfilled Full Time Positions: Enter the number of unfilled full time positions, as of 8/31/2017, for each employee type. Column 13: Number of Unfilled Part Time Positions: Enter the number of unfilled part time positions, as of 8/31/2017, for each employee type. Labor Competition Column 14: Name of Primary Competitor for Employees. Enter the name of your primary competitor for employees. Column 15: City of Primary Competitors. Enter the name of the city where your primary competitor for employees is located. Column 16: State of Competitor. Enter the name of the state where your primary competitor for employees is located. Column 17: Type of Business. Select the type of business of your primary competitor for employees from the drop down list. Additional Questions Question 1: If you assign raises, when do you they take effect? Start of a fiscal year, start of calendar year, or other time of year? Check the applicable answer. Navigant 9/5/2017 Page 24

26 Worksheet E: Program Employee Staffing and Turnover WORKSHEET E: EMPLOYEE TURNOVER This Worksheet captures data for the number of direct care employees and unfilled positions on the last day the provider fiscal year reported on this worksheet, the number of employees who were continuously employed throughout the provider fiscal year, and the number of employees who left the agency during the provider fiscal year. This worksheet also captures information on the reasons why employees leave and the impact that employee turnover has on an organization. We understand that your agency s payroll reporting records may not coincide with the last day of your fiscal year end date. If this is the case, and it is easier for you to report the information for this Worksheet based on your most recent payroll reporting period, please provide responses based on the last day of that payroll reporting period. Line Description The lines in this Worksheet represent different employee types. Program Employees, Lines 1 through 14 Lines 1 through 14 capture the number of employees, and unfilled positions. Enter the requested information for each employee type on lines 1 through 12. If there are Other Program Employees that you identified in Worksheet C, please enter the relevant information in aggregate on line 13. Information for these employees should be reported consistently with how they were reported on Worksheet C. The survey will automatically sum Lines 1 through 13 on Line 14. Do not enter data into this line. Please fill out Columns 1 9, described below, for each of the employee types. Full time Employees Note: Please use the definition of full time employees described in Worksheet A. Column 1. Number On Payroll At End Of Provider Fiscal Year. Enter the total number of fulltime employees in filled positions as of the end of your most recent fiscal year. Navigant 9/5/2017 Page 25

27 Worksheet E: Program Employee Staffing and Turnover Column 2. Number Continuously Employed During Fiscal Year. Enter the total number of full time employees employed continuously from the start to the end of your most recent fiscal year. Column 3. Number Who Left the Agency During Fiscal Year. Enter the total number of fulltime employees who left the agency during your most recent fiscal year. Part time Employees Note: Please use the definition of part time employees described in Worksheet A. Column 4. Number on Payroll at End of Fiscal Year. Enter the total number of part time employees in filled positions as of the end of your most recent fiscal year. Column 5. Number Continuously Employed During Fiscal Year. Enter the total number of part time employees, who were employed continuously from the start to the end of your most recent fiscal year. Column 6. Number Who Left the Agency During Fiscal Year. Enter the total number of parttime employees who left the agency during your most recent fiscal year. Unfilled Positions Column 7. Full Time Employees. Enter the total number of full time vacant positions as of the last day of your most recent fiscal year. Column 8. Part Time Employees. Enter the total number of part time vacant positions as of the last day of your most recent fiscal year. Additional Questions Question 1. What are the THREE most frequent reasons that employees cite for separation? Mark ʺXʺ in the 3 boxes that apply. Select your choices separately for the two categories of employees shown: (1.1) unlicensed direct care employees and (1.2) unit supervisors and staff supervisors. Question 2. What are the THREE largest impacts of staff turnover on your organization? Mark ʺXʺ in the 3 boxes that apply. Select your choices that reflect what you feel are the three largest impacts of staff turnover on your organization. Enter another reason in the Other box if you desire. Navigant 9/5/2017 Page 26

28 Worksheet F: Employee Health Insurance Benefits WORKSHEET F: EMPLOYEE HEALTH INSURANCE BENEFITS This worksheet assesses the health insurance benefits that an agency does or does not offer. If your organization offers health insurance, please complete Table 1 only. If your organization does not currently offer health insurance benefits, complete Table 2 only. Please enter your response to each question in Column 1 in Column 3. Follow the example in Column 2. Navigant 9/5/2017 Page 27

29 Worksheet G: Employee Retirement Benefits WORKSHEET G: EMPLOYEE RETIREMENT BENEFITS This worksheet assesses the retirement benefits that an agency does or does not offer. Please enter your response to each question from Column 1 in Column 3. Follow the example in Column 2. If your organization offers retirement benefits, please complete Table 1 only. If your organization does not currently offer retirement benefits, complete Table 2 only. Navigant 9/5/2017 Page 28

30 Worksheet H: Case Management Questions WORKSHEET H: CASE MANAGEMENT QUESTIONS This worksheet assesses variation in time spent serving participants and reasons that might affect the variation. Supplemental Information Participants Line 1: How many participants do you or your agency currently serve? Enter the total number of participants currently served by your agency under each waiver. Lines 2 5: Looking at your total caseload, approximately how many participants require, on average, the following amounts of case management per month: Line 2: 0 3 Hours per Month. Enter the total number of participants served by you or your agency who require approximately 0 to 3 hours of case management per month. Line 3: 4 6 Hours per Month. Enter the total number of participants served by you or your agency who require approximately 4 to 6 hours of case management per month. Line 4: 7 9 Hours per Month. Enter the total number of participants served by you or your agency who require approximately 7 to 9 hours of case management per month. Line 5: 10+ Hours per Month. Enter the total number of participants served by you or your agency who require more than 10 hours of case management per month. Note: the sum of Lines 2 through 5 should equal the value entered in Line 1 for each column. Supplemental Information Reasons for Variation among Participants This section asks you to consider reasons why the time spent providing case management to each participant each month might vary among participants. Please also consider the types of activities that tend to require more time for some participants than others. Line 6: What are the most common reasons for exceeding six hours of case management per month for a given participant? Please select all that apply. Please select the most common reasons that you think contributes to cases when a participant requires more case management time than six hours during a month. If you select the Other option, please describe the reason(s) in the text box provided. Navigant 9/5/2017 Page 29