Department for Medicaid Services (DMS) HCBS Provider Cost and Wage Survey

Transcription

1 Department for Medicaid Services (DMS) HCBS Provider Cost and Wage Survey Cost Survey Instructions February 25, 2019 Survey Due Date: March 29, 2019 Submit completed survey to: Prepared by:

2 Table of Contents A. Introduction... 1 A.1 Accessing the Survey... 4 A.2 Reporting Period... 4 A.3 Completing and Submitting the Survey... 4 B. Completing General Survey Worksheets... 5 B.1 Contact Info & Revenues... 5 B.2 Service Area... 6 B.3 Waivers & Services... 6 B.4 Non-Direct Staff... 6 B.5 Total Costs... 8 B.6 Vehicle Costs B.7 Benefits C. Completing Service-Specific Worksheets C.1 Home and Community Based Services C.2 Day Services C.3 Supported Employment C.4 Behavioral Services C.5 Nursing Services C.6 Therapeutic Services C.8 Case Management C.9 Support Broker C.10 Financial Management Services... 50

3 KY DMS HCBS Rate Study Cost Survey Instructions Page 1 A. Introduction The Department for Medicaid Services (DMS) is conducting a rate study to establish a new ratesetting methodologies for home and community-based services (HCBS) delivered via 1915(c) waivers in Kentucky ( waiver programs ). The data collected from this cost and wage survey ( survey ) will help inform the rate study, along with other data sources. This document contains instructions to assist providers in completing the survey. Please note that home-delivered meal providers will receive a separate survey. A provider is defined as a controlling entity, agency or corporate organization that providers HCBS and generally possesses a Primary National Provider Identification (NPI) number. All providers are strongly encouraged to complete the survey with the exception of providers that do not designate wage rates as they may not have the financial structure necessary to report costs and wages. These are providers that do not have a business tax identification number or used their social security number as a business tax identification number. The survey website provides additional copies of the surveys and corresponding instructions along with a list of frequently asked questions: If you have questions regarding the survey, please HCBSRates@Navigant.com or call 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. Broadly, the survey is designed to collect information in five primary areas: Administration and program support staffing Total costs to provide services Benefits for direct service staff Direct service staff hours and wages Direct staff time and staffing All agencies should complete the following forms: Contact Information and Revenue Service Area Waivers and Services Total Costs Vehicle Costs Benefits for Direct Service Staff Non-Direct Staff

4 KY DMS HCBS Rate Study Cost Survey Instructions Page 2 Providers should also fill out all additional worksheets related to the specific services they provide. The cost survey attempts to account for a wide variety of program costs, through the service-specific worksheets, and may not require providers to complete every row of the worksheets. The survey is interactive and will only display those service-specific worksheets needed based on the services that providers indicate that they deliver on the tab labeled Waivers & Services ). The service-specific worksheets are organized by service categories, which are designed to group together different services with common service delivery characteristics and cost structures. The table below provides a crosswalk of the waiver service category to the corresponding waiver services and service-specific worksheets Table A.1: Waiver Service Categories and Corresponding Waiver Services and Worksheets Waiver Service Category Home-Based Services Day Services Behavioral Services Attendant Care Waiver Services Community Access Community Living Supports Companion Homemaking Home and Community Based Supports Personal Care Personal Assistance Respite Specialized Respite Level I Specialized Respite Level II Adult Day Health ADHC Level I ADHC Level II Day Training Adult Day Training Behavior Supports Positive Behavior Support Person Centered Coaching Consultative, Clinical and Service-Specific Worksheets Home-Based Services Time Home-Based Services Factors Day Services Time Day Services Factors Day Services Groups Behavioral Services Time Behavioral Services Factors

5 KY DMS HCBS Rate Study Cost Survey Instructions Page 3 Waiver Service Category Nursing Residential Services Therapeutic Services Case Management Supported Employment Participant-Directed Services (PDS) Waiver Services Therapeutic Group Counseling Individual Counseling Family Training Nursing Supports Skilled Services LPN Skilled Services RN Skilled Services RT Residential Support Level I Residential Support Level II Supervised Residential Care I Supervised Residential Care II Supervised Residential Care III Technology-Assisted Residential Occupational Services Physical Therapy Speech Therapy Case Management Supported Employment Support Broker Financial Management Services Service-Specific Worksheets Nursing Services Time Nursing Services Factors Residential Services Time Residential Services Factors Therapeutic Services Time Therapeutic Services Factors Case Management Time Case Management Factors Supported Employment Time Supported Employment Factors Supported Employment Groups Support Broker Time Support Broker Factors Financial Management Time Financial Management Factors

6 KY DMS HCBS Rate Study Cost Survey Instructions Page 4 Throughout the survey, fields in which users may record data are shaded in light green. Examples are shaded in grey. Dark green fields are automatically calculated based on other responses. A.1 Accessing the Survey The survey has been built in Microsoft Excel, in a version compatible with Excel 97 and more current versions. The survey includes macros that must be enabled. Users may get a warning when opening the document and should select Enable Content. If you are having issues with accessing the survey, please contact Navigant at HCBSRates@Navigant.com \ Click on Enable Content before proceeding through the survey. A.2 Reporting Period Providers should provide information from their most recently completed fiscally year for which audited financial statements or general ledger data is available. A.3 Completing and Submitting the Survey When saving the forms, please add your agency s name to the beginning of the file name; e.g., ABC Agency HCBS Provider Rate Study. The deadline for submitting the completed survey is March 29, Please submit completed forms to Navigant at HCBSRates@Navigant.com. If there are any costs or issues that you believe should be considered but were not included in the survey, note those issues (and any other comments) in the transmittal when submitting the survey. If you have any questions, please contact Navigant at HCBSRates@Navigant.com or Survey Due Date: March 29, 2019 Submit completed survey to: HCBSRates@Navigant.com

7 KY DMS HCBS Rate Study Cost Survey Instructions Page 5 B. Completing General Survey Worksheets The following subsections provides a description of the worksheets that should be completed by all providers, regardless of the services offered. B.1 Contact Info & Revenues Use this sheet to record contact information for your agency. Specifically, input the following information: The name of your agency The agency ID number(s) used by your agency to bill for services The name of the individual responsible for the information submitted through the survey and that individual s: - Job title - Phone number - - Address The agency type for your agency (for profit or non-profit) The fiscal year begin date and end date of the agency s most recently completed fiscal year for which audited financial statements or general ledger data is available. This worksheet also requests information regarding revenues from your agency s most recently completed fiscal year for which audited financial statements or general ledger data is available. Report agency revenues using the following categories: Waiver Program Revenues include any payments received by your agency for providing services covered under waiver program(s). Non-Waiver Program Revenues input revenues that are not associated with the waiver programs, including payments from private insurers and other payers (e.g., behavioral health services). Fundraising/Grants Revenue input any revenues from fundraising activities or grants received by your agency. Other include any other revenues that were not allocated to the previous categories. Total Total agency revenues will automatically be calculated based on the sum of the four previous amounts. The total agency revenue amount should match your reported total gross revenue from the fiscal year you are reporting. This worksheet sheet asks for your agency s current staffing level, divided between full-time

8 KY DMS HCBS Rate Study Cost Survey Instructions Page 6 staff, part-time staff and contracted employees. Contracted employees are those considered to be independent contractors. For the purposes of this section full-time employment is defined as 30 or more hours per week while part-time is fewer than 30 hours Finally, this worksheet asks for your agency s number of clients by program. Please report the total number of unique clients served during the fiscal year reported by the following payers: Total Waiver Program Clients total clients whose services are covered by the waiver programs. Total Non-Waiver Medicaid Clients total Medicaid clients whose services are not covered by the waiver programs. Total Other Clients Include total of any other clients not allocated in the previous categories. B.2 Service Area This form includes check boxes for each county where waiver services are provided. Select the counties where waiver services are provided by your agency. B.3 Waivers & Services This form includes two parts. The first part asks that you indicate if your organization is a Financial Management Agency (FMA). When the check box to this part is selected, a worksheet called FMA Questionnaire will be unlocked, to be completed by the agency that identifies itself as an FMA. The main part of the worksheet consists of check boxes for each service covered under the different waiver programs. For each waiver program, select the waiver service(s) provided by your organization. When a check box has been selected, the corresponding Staff Time allocation, Staffing Patterns and Groups (if applicable) worksheets for that service will be unlocked for completion. B.4 Non-Direct Staff This sheet is to be used to record information regarding your agency s administrative and program support staff, but not those employees who primarily provide direct care. All data should be from your agency s most recently completed fiscal year indicated in the survey. Following are descriptions of the fields included in this worksheet: Title Input the job title for each administrative or program support employee. If your agency has multiple employees within a given job title (e.g., three Human Resource Specialists), you may list them in the same row if their time is allocated similarly (e.g., each spends 100 percent of their time on administrative functions; see the discussion below for the Percent of Time Allocated to Waiver Programs column). Do not combine staff with different job titles. Admin./ Program Support Staff Identify whether the staff is administrative staff or

9 KY DMS HCBS Rate Study Cost Survey Instructions Page 7 program support staff. Administrative staff mainly support the operations of the agency, rather than performing supporting activities for the provision of direct care. Employees who are typically considered administrative include general management, financial/accounting, and human resource staff. o Program support staff are those staff who mainly perform activities that support the provision of direct care but are not providing that care themselves. Examples include staff responsible for food preparation for adult day programs, training direct care workers, program development, supervision, and quality assurance. Staff do not need to be listed individually; they can be grouped by job title, however, please complete a separate row for each job title/ classification. Contracted/ Full Time and Part Time Identify whether the staff is contracted or full time/part time employees. Do not mix full and part-time workers in the same row. Number of Employees Record the number of full-time equivalent staff in each job title employed by your agency. Total Salary and Regular Wages Paid Input the wages earned in the fiscal year reported by the individual(s) associated with each job title. Note: Only report actual wages paid, rather than salary levels (e.g., if an employee was hired midyear, report the wages that they earned and not their annual salary level). Total Overtime Paid Input the total overtime wages paid for the fiscal year to the individuals reported for each title. Cost of Optional Benefits Input the cost to your agency for optional benefits provided for the fiscal year reported to the individual(s) associated with each job title. Optional benefits include health insurance, dental insurance, retirement, and other benefits that are provided at your agency s discretion. - Do not include mandatory employee related expenses (ERE) such as Social Security, Medicare, unemployment insurance, and workers compensation. These costs will be calculated separately. - Note: Only report costs paid by your agency; exclude employee costs such as their share of health insurance premiums or retirement contributions. Percent of Time Allocated to Waiver Programs The next three columns relate to the amount of each employee s time that is devoted to your agency s waiver programs. - Direct Care Input the percentage of time that the employee is providing direct care services (although this sheet is only intended to capture information regarding administrative and program support staff, this column has been included because these staff, particularly in smaller agencies, may provide direct care at times). - Administration Input the percentage of time that the employee is performing waiver related administrative functions. - Program Support Input the percentage of time that the employee is performing

10 KY DMS HCBS Rate Study Cost Survey Instructions Page 8 waiver related program support functions. Percent of Time Allocated to Other Programs Input the portion of each employee s time that is allocated to programs other than those reported in the previous section. This column is included because some employees support multiple programs so it would be inappropriate to allocate their total salary and benefits costs to the waiver program (e.g., an executive director may lead an agency that provides both waiver and non-waiver programs so only a portion of their time should be allocated to the waiver programs). Note: If your agency does not already have a methodology for allocating costs across programs, it is recommended that your agency track time spent for one week on nonwaiver programs versus waiver program programs. For waiver programs, tracking would be needed of direct care, admin and support hours. After that week, each employee s time would be allocated based the data collected. For example, if an employee worked 40 hours and 10 of their hours were related to a waiver program, 25 percent of that employee s time would be allocated to direct care, administration, and/or program support of the waiver programs, as appropriate, with the remaining 75 percent input in the Other Programs column. If this approach is not feasible for your agency, please contact Navigant to discuss other potential allocation methodologies. Note: The total of the time allocated across waiver programs (direct care time, administration, and program support) and other programs should equal 100 percent. If it does not, an error message will appear to the right of the table. B.5 Total Costs The survey includes a form to capture your agency s total costs. The purpose of this worksheet is to capture the total costs of the agency, and to allocate those costs between the waiver programs and non-waiver programs. There are not always clear distinctions between direct care, program support, and administration costs and definitions of these terms vary. For the purposes of this survey, the following guidelines should be used: Direct care costs include the salaries and employee-related expenses (including unemployment insurance and workers compensation) of direct care workers and client transportation expenses, the space in which programs are delivered (e.g., the room in which a Day Treatment program is operated), and program materials and supplies (e.g., art supplies). Administrative costs are those associated with the operation of your agency, but which are not program-specific. Employees that are typically considered administrative include general management, financial/accounting, and human resource staff. Expenses associated with these staff (e.g., their office space, utilities, etc.) are also considered administrative. Program support costs are expenses that are neither direct care nor administrative. Such activities are program-specific, but not billable. Examples include staff responsible for food preparation for an adult day program, training direct care workers, program development, supervision, and quality assurance. Expenses associated with these staff (e.g., their office space,

11 KY DMS HCBS Rate Study Cost Survey Instructions Page 9 utilities, etc.) are also considered program support. The financial information provided on this form should correspond to each agency s most recently completed fiscal year for which audited financial statements or general ledger data is available. Each cost report line represents a particular type of expenditure. Cost report lines are classified into five major groups: Employee Salaries and Wages Employee Taxes and Benefits Non-Payroll Administrative Costs Non-Payroll Program Support Expenses Facility, Vehicle and Equipment Related Expenses To report costs in this form, your agency should allocate costs incurred in the fiscal year between the categories identified. For each line in this form, report the total expenses incurred by your agency in Excel column D Total Expenses Per General Ledger. These expenses should match the total expenses from your financial statements or general ledger. In Excel column E Expenses Allocated to Waiver Programs, allocate the expenses related to your waiver programs only (these would be expenses related to waiver funded clients). In Excel column F Expenses for Room and Board Program Costs, report expenses related to room and board costs for programs like residential services, e.g., group home and developmental home programs. For example, when reporting the total rent or mortgage costs in Line 51 of the form, report the total rent and mortgage costs for group homes and developmental homes in this column, regardless of whether someone is funded through a waiver program. According to the Centers for Medicare and Medicaid Services (CMS): * The term room means shelter type expenses, including all property-related costs such as rental or purchase of real estate and furnishings, maintenance, utilities, and related administrative services. The term board means three meals a day or any other full nutritional regimen. *Instructions, Technical Guide and Review Criteria, Application for a 1915(c) Home and Community-Based Waiver, page 47, January Disabled and Elderly Health Programs Group CMS. Expenses related to your agency s non-waiver programs will automatically be calculated in Excel column G by subtracting the expenses related to the waiver programs and expenses related to room and board costs from the total expenses reported in Excel column D. Please

12 KY DMS HCBS Rate Study Cost Survey Instructions Page 10 review the values in column G to confirm your allocation of expenses to the other columns is reasonable. Employee Salaries and Wages: In lines 1 through 10, report total salaries and wages paid and accrued, by employee category. Please report total gross salaries and wages paid and accrued, including bonuses, sick time pay, and overtime pay by employee category. If an employee fits into more than one category (for example, an admin employee that does some direct care), then you would allocate the salary based on the time spent between those two functions. Lines 2-3: Direct Care Employee salaries and wages are defined as costs associated with employees who provide direct face-to-face support for clients. Salaries and wages of employees who manage direct care services but who do not directly work with clients/residents should be entered into the appropriate Direct Care Supervisor cost report line. Line 4: Maintenance employee salaries and wages are defined as costs associated with employees who provide janitorial, housekeeping, repair, and maintenance services. Administrative employee salaries and wages are defined as costs associated with employees who provide management, accounting, information technology, human resource and clerical services, etc. inside of the agency office. Line 5: Administrative employee salaries and wages are defined as costs associated with employees who do not provide direct face-to-face support for clients and do not support program specific activities. Administrative employees typically include general management, financial/accounting, and human resource staff. Line 6: Program support employee salaries are costs that are neither direct care nor administrative. Such activities are program-specific, but not billable. Examples include food preparation workers for adult day services, staff responsible for training direct care workers, program development, service coordination, and quality assurance. Interpreter and sign language staff salaries and wages can be reported here. Lines 7-9: Report wages paid to contracted direct care, program support and administrative staff. Line 10: The form will automatically calculate the sum of lines 2 through 9. The resulting number should match the total employee salaries and wages costs from your most recently completed fiscal year. Employee Taxes and Benefits Lines 11 through 16 capture costs incurred by your agency related to employee payroll taxes, insurance and benefits. Only the portion of the employee benefits and payroll taxes paid and accrued by the agency must be reported on these lines. 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 Employee Salaries cost report lines).

13 KY DMS HCBS Rate Study Cost Survey Instructions Page 11 Line 12: The Employee Payroll Taxes cost report lines capture the employer s portion of any Federal Insurance Contributions Act (FICA) including social security and Medicare taxes, Federal Unemployment Insurance (FUI), State Unemployment Insurance (SUI), Workers Compensation and other payroll related taxes. Lines 13-14: The Employee Insurance cost report lines capture the employer s portion of any costs related to employee health insurance, dental insurance, life insurance, disability insurance and client fringe benefits. Please report the employer s portion of Employee Health Insurance costs. Other Insurance can include but are not limited to dental, life, short term and long-term disability insurance. Line 15: The Employee Other Benefits cost report lines capture the employer s costs related to workers compensation insurance, retirement, and any other benefits your agency offers to employees. Enter the employer s portion of any costs related to employee retirement programs including employer contributions to pension plans, employer contributions to 401k plans, or other retirement-related programs Line 16: The form contains a formula that calculates the sum of Lines 12 through 15. The resulting number should match the total employee taxes and benefits costs from your most recently completed fiscal year Non-Payroll Administrative Costs Lines 17 through 39 capture non-payroll costs associated with administrative activities. Allocate associated costs into applicable categories. Line 18: Report costs for office equipment and furniture that are not for direct care services. Equipment costs related to direct care should be reported in Lines 62 and 63. Line 19: Report interest expenses incurred by your agency. Do not report interest expenses related to mortgages. Interest costs related to mortgage expenses should be reported in Line 51. Line 20: Enter the costs related to non payroll taxes, such as property tax and other Federal taxes. Line 21: Enter costs related to licenses, certifications and accreditation fees. Line 22: Enter the costs related to hiring staff, including expenses related to recruiting, background checks, drug testing, etc. Onboarding expenses should not be reported here, but rather in Line 23 which is associated with staff training and development. Line 23: Enter the costs related to staff training and development. These costs should include hiring a trainer, training materials and fees related to sending staff to a training session. These costs do not include the salaries of the staff who are being trained; such salaries should be reported in the Salaries and Wages portion of this worksheet. Training and development costs specifically related to direct care should be reported on Line 44. Line 24: Enter the costs related to general liability insurance, directors and officer s

14 KY DMS HCBS Rate Study Cost Survey Instructions Page 12 insurance, professional malpractice insurance, buildings, contents and grounds insurance, and other types of insurance. Do not enter the costs related to vehicle insurance as they should be reported in Line 60 of this form. Do not include the employer s portion of employee health and benefits insurance (these should be entered in Lines 12 through 15 as appropriate). Line 25: Enter the costs related to information technology supplies and software, etc. separate from other supplies. Information technology supplies related to direct care should be directly allocated to the Non-Payroll Program Support Expenses and other program supplies should be reported in the Non-Payroll Program Support Expenses section of the form. Line 26: Enter costs related to office supplies. Line 27: Enter costs related postage. Line 28: Enter costs related advertising and marketing. Line 29: Enter costs related to dues and subscriptions. Line 30: Enter costs related to consulting services such as legal, accounting or training costs. Line 31: Enter travel costs incurred for the fiscal year. In this line do not include clientrelated transportation costs or direct care vehicle reimbursement costs. These costs should be reported in Line 45 Transportation Costs Client related. Line 32: Enter costs related to translating materials. Line 33: Enter bad debt expenses for the fiscal year. Line 34: Enter the allocated portion of administrative expenses at a central corporate office outside of the agency s principal place of business applicable to the local level. Lines 36-38: Enter the costs related to other administrative items. Amounts reported on must be accompanied by a description of the reported costs. Line 39: The form will automatically be calculated as the sum of lines 18 through 38. The resulting number should match the total non-payroll administrative costs from your most recently completed fiscal year. Non-Payroll Program Support Expenses Lines 41 through 49 capture non payroll expenditures made for the support of agency programs. Allocate associated costs into applicable categories, paying particular attention to allocating costs related to room and board. Line 41: Enter expenditures for materials used in client care or program support services. Some examples of costs that should be reported here include:

15 KY DMS HCBS Rate Study Cost Survey Instructions Page 13 - Room and Board Supplies Enter the costs related to room and board supplies, including bedding, cleaning supplies, personal hygiene, and medical supplies. - Food and Supplies Enter the costs related to food and food supplies. - Activity Supplies: Enter costs for recreational activities or supplies for activities (for example art and craft supplies.) - Other Direct Care Supplies Enter the supply costs related to providing direct care such as client medications. Line 42: Enter costs related to devices and technologies used for direct care. Line 43: Enter costs related to direct care staff participating in activities. For example, if your agency pays for the costs of direct care staff participating in activities with the client, report those costs here. Line 44: Enter the costs related to staff training and development for the provision of direct care services. Line 45: Enter client service related transportation expenses including transportation reimbursements made to program staff. This includes the transportation of direct care workers to meet clients. Do not include the costs associated with vehicle insurance or maintenance (these costs should be reported in the appropriate cost report lines). Lines 46-48: Enter the costs related to other program support activities. Amounts reported on these lines must be accompanied by a description of the reported costs. Line 49: The form will automatically be calculated as the sum of lines 41 through 48. The resulting number should match the total non-payroll program support costs from your most recently completed fiscal year. Facility, Vehicle and Equipment Related Expenses Lines 51 through 64 capture non-payroll related facility, vehicle, and equipment expenses. Do not include costs associated with facility or vehicle staff salaries or contractor fees (these costs should be reported in the appropriate salary and contracted cost report lines). Line 51: These cost report lines capture rental, mortgage and depreciation expenses related to your agency s facilities. Lines 52-53: Enter total square footage for all facilities reported under rent, mortgage and depreciation expenses reported in Line 51. In Line 53, report the total square footage designated as administrative space. Lines 54-55: These cost report lines capture costs related to utilities such as disposal services, telephones, cellular phones, other communications devices, cable, internet, electrical power, gas, heating, facility water, garbage, sewage, and other utilities. This can include security costs and costs associated with fire or other hazard detectors, alarms and sprinkler systems. In Line 54 report the administrative portion of these costs

16 KY DMS HCBS Rate Study Cost Survey Instructions Page 14 and in Line 55 report the direct care related costs. Line 56: These cost report lines capture all non-payroll maintenance and repair expenses related to your agency s facilities. Include any costs associated with renting temporary substitute facilities during repair time. Line 57: These cost report lines capture any facility janitorial, landscaping, repairs, etc. that are not included as part of a building lease agreement. Vehicle Related Costs In Lines 58 through 61, report the requested vehicle related costs. Line 58 Report total costs incurred by your agency for acquiring or leasing vehicles for the fiscal year reported. Line 59 Report total costs related to maintenance and repairs that your agency incurred for the fiscal year reported. Include any costs associated with renting substitute vehicles during repair time. Line 60 Report total costs related to insurance for vehicles. Line 61 Report vehicle depreciation costs for the fiscal year reported. We assume costs related to vehicles acquired in prior years will be reflected here. Line 62: Report the total costs related to acquiring, repairing, and maintaining equipment that is used in the provision of direct care services. Line 63: Report equipment depreciation costs for the fiscal year reported. Line 64: The form will automatically be calculated as the sum of lines 51 through 63. The resulting number should match the total facility, vehicle and equipment related expenses from your most recently completed fiscal year. Line 65: The form will automatically calculate your agency s total costs for the fiscal year reported. The total costs in Line 65 in Excel column D should match the total costs reported in your financial statements or general ledger for the fiscal year reported in the survey. B.6 Vehicle Costs This form gathers additional information about agency vehicle costs. The purpose of this form is to allocate total vehicle costs reported in the Total Costs worksheet across the services that the agency provides based on the total mileage associated with providing each service. Total vehicle costs reported will automatically populate in the schedule based on the information reported in the Total Costs form. In Line 1, first enter the total miles traveled for providing services for the fiscal year reported. Then, continuing in Line 1, allocate these total miles between the different services that the agency provides. If your agency does not provide a specific service, please enter a 0. In Line 2, an allocation percentage will automatically be calculated that represents the percentage of total

17 KY DMS HCBS Rate Study Cost Survey Instructions Page 15 miles attributed to each service. Based on these allocation percentages, the total vehicle costs in Lines 3 through 8 will be allocated across the programs. In Lines 4 and 5, please break down the total vehicle acquisition/lease cost reported on Line 3, for vehicles with lifts versus the total cost for all other vehicles. The sum of Lines 4 and 5 should match the total vehicle costs in Line 3. In Lines 10 and 11, please report the total number of vehicles with lifts and the total number of other vehicles in the agency fleet. B.7 Benefits This worksheet requests information regarding benefits and other employee related expenses associated with direct service staff. Consider only direct service staff when completing this worksheet; do not include administrative and program support staff as these costs are captured on the Total Costs schedule. There are separate columns for full-time and part-time direct service staff. If your agency has a definition of full- and part-time particularly a definition used to determine eligibility for benefits use that definition to determine who is full- and part-time. Otherwise, use 30 hours as the definition for full-time. The following are descriptions of the fields included in this worksheet. Staffing Line 2 Input the number of direct service staff currently employed by your agency. Holidays Lines 4 Using the drop-down list, indicate whether direct service staff are eligible for holiday pay. Lines 5 Record the number of holidays that direct service staff receive. Vacation, Sick Time, and Personal Days Line 7 Indicate if direct care staff are eligible for other paid time off in addition to holidays Line 8 Indicate the average number of sick days that direct care staff are eligible to receive. Line 9 Indicate the average number of vacation days that direct care staff are eligible to receive. Line 10 Indicate the average number of personal days that direct care staff are eligible to receive. Health, Vision, and Dental Insurance Lines 12 Indicate whether direct service staff are eligible to receive health insurance from your agency.

18 KY DMS HCBS Rate Study Cost Survey Instructions Page 16 Lines 13 Record the number of direct service staff who are eligible for the health insurance program (the number should be no more than the figure reported on Line 2). Lines 14 Record the number of direct service staff who are enrolled for the health insurance program (the number should be no more than the figure reported on Line 13). Line 15 Indicate if your organization contributes to health insurance premiums. Line 16 Input the average amount a typical employee with single coverage will contribute toward health insurance premiums. Line 17 Input on average how much your organization contributes toward the monthly plan premium of one typical employee with single coverage? If your organization selfinsures any portion of the health insurance, report the premium equivalent of self-insured costs plus any other premiums paid (e.g. stop-loss premiums, ASO fees). Line 18 Input on average how much the total monthly premium is for a typical employee with single coverage (this number should equal the sum of lines 16 and 17). Line 19 Input the average annual deductible for the health insurance offered for individual coverage. Line 20 Input the average annual deductible for the health insurance offered for family coverage. Lines 21 Indicate whether direct service staff are eligible to receive vision insurance from your agency. Lines 22 Record the number of direct service staff who are enrolled in the vision insurance program (the number should be no more than the figure reported on Line 2). Line 23 Input your agency s total spending on vision insurance premiums for direct care staff in the most recently completed fiscal year. Do not include costs for administrative or program support staff. Do not include employee contributions. Lines 24 Indicate whether direct service staff are eligible to receive dental insurance from your agency. Lines 25 Record the number of direct service staff who are enrolled in the dental insurance program (the number should be no more than the figure reported on Line 2). Line 26 Input your agency s total spending on dental insurance premiums for direct care staff in the most recently completed fiscal year. Do not include costs for administrative or program support staff. Do not include employee contributions. Retirement Line 28 Indicate whether your agency contributes to a 401k, 403b or other retirement plan for your direct care staff. Line 29 Indicate whether your agency participates in the Kentucky Retirement System.

19 KY DMS HCBS Rate Study Cost Survey Instructions Page 17 Line 30 Record the number of direct service staff who are currently receiving retirement contributions from your agency. Line 31 Input your agency s average retirement contribution (as a percent of wages) for those direct service staff that participate in the retirement offering. Do not include any employee contributions. Other Benefits Your agency may offer other benefits to staff. The following questions relate to these other benefits: Lines 33 Indicate whether your agency provides other benefits. Lines 34 List the other benefits that are provided. Lines 35 Record the number of direct service staff who are participating in the applicable benefit. Line 36 Input total spending on these benefits for direct care staff in the most recently completed fiscal year. Do not include costs for administrative or program support staff. Unemployment Insurance and Workers Compensation Line 38 Many agencies make quarterly payments to the Kentucky state unemployment insurance based on an employer-specific tax rate. If your agency makes payments based on a tax rate, report its state unemployment insurance tax rate for Do not include the federal unemployment insurance tax. Line 39 Some agencies, including non-profits, may elect to pay the actual cost of benefits paid to former employees rather than making payments based on a computed tax rate. If your agency makes payments in lieu of contributions, report the total payments made in Do not include federal unemployment insurance costs. - Note: Your agency should complete either Line 38 or Line 39, but not both. Line 40 Input your workers compensation cost for Direct Service Staff under your 2019 policy period as a rate for each $100 in wages paid. If your agency has multiple policies, provide a weighted average of the policies associated with direct care staff in your agency s waiver programs.

20 C. Completing Service-Specific Worksheets C.1 Home and Community Based Services KY DMS HCBS Rate Study Cost Survey Instructions Page 18 The two survey forms Staff Time and Staffing Patterns for Home and Community-Based Services, are similar so this section provides the instructions for each of these categories. Staff Time The Staff Time forms are to be used to record information regarding your agency s direct care staff for home-based services, but not those employees who are administrative and program support staff. If an employee splits their time between administrative and direct care work, only include the portion of their time and salary related to direct care. All figures should be for your agency s most recently completed fiscal year indicated in this survey. The following are descriptions of the fields included in this worksheet: Title Input the job titles for each direct care staff. If your agency has multiple employees within a given job title (e.g., three caregivers), you may list them in the same row if their time is allocated similarly (e.g., each spends 100 percent of their time on direct care functions. Do not combine staff with different job titles in a single row. Employee/Contractor Identify whether the staff is employed by your agency or is a contracted employee. Supervisor Identify whether the staff is a supervisor. Number of Individuals Record the number of staff in each job title employed by your agency. Total Regular Hours Paid: Input the total number of non-overtime hours paid to an individual associated with each job titles. Total Overtime Hours Paid Input the total number of overtime hours paid to an individual associated with each job title. Total Regular Wages Paid Input the wages earned in the fiscal year reported by the individual(s) associated with each job title. Note: Only report actual wages paid, rather than salary levels (e.g., if an employee was hired midyear, report the wages that they earned and not their annual salary level) Total Overtime Wages Paid Input the total overtime wages paid for the fiscal year to the individuals reported for each title. Percent of Time Allocated to Waiver Services The next ten columns relate to the amount of each employee s time that is devoted to your agency s specific home-based services. For each service, input the percentage of time that the employee is providing direct care services.

21 KY DMS HCBS Rate Study Cost Survey Instructions Page 19 Staffing Patterns For many of these services, the Staffing Pattern form includes separate columns for staff delivering different services with different qualifications. Specifically: The Home and Community-Based form includes different columns for each of the different services included (e.g., Attendant Care, Community Access, Respite, etc.) Agency Caseload and Service Design Line 1 Record the number of individuals receiving the applicable service from your agency. Line 2 Input the average number of client visits that a direct service staff person conducts per week. Line 3 Input the average number of hours that a client visit lasts. Equipment and Supplies Line 4 Input the total cost of capital equipment directly related to service provision, if any is applicable. Line 5 If applicable, input the average life in years of purchased equipment. Line 6 If equipment costs are noted in Line 4, list the types of equipment included in the expense. Line 7 Input the total cost of program supplies directly related to service provision. Line 8 If program supply costs are noted in Line 7, list the types of supplies included in the expense. Staffing Pattern This section requests information regarding the typical week for the direct service staff. Line 9 Input the number of hours per week that a direct service staff person typically works. Line 10 The number of hours per week that a direct service staff person is engaged in service delivery. This line is automatically calculated by multiplying Line 2 (number of visits per week) by Line 3 (number of hours per visit). Line 11 Input the number of hours per week that a direct care staff person is participating in Plan of Care (PCP) meetings. Line 12 Input the number of hours per week that a direct service staff person completes or participates in member assessments at which the member is not present. Line 13 Input the number of hours per week that a direct service staff person is traveling between individual visits with clients.

22 KY DMS HCBS Rate Study Cost Survey Instructions Page 20 Line 14 Input the number of hours per week, on average, that a direct service staff person loses due to missed appointments. Do not include time that is redirected to another activity accounted for within this schedule. For example, if a consumer misses a four-hour appointment, it is unlikely that four hours is lost because the staff person instead catches up on paperwork, is sent home, etc. Line 15 Input the number of hours per week that a direct service staff person spends on recordkeeping activities, other than documentation that occurs during service provision. Do not include documentation associated with the completion of formal assessments. Line 16 Input the number of hours per week that a direct service staff person is engaged in employer time and not performing direct service duties. Examples include staff meetings, filing employer required paperwork (not related to service delivery), and receiving counseling from a supervisor. Do not include time spent on training programs. Lines If there are activities that are part of a staff person s typical week, but not listed on the survey, type in a description and indicate the number of hours per week that a staff person typically spends in that activity. Line 20 This line calculates whether all staff hours have been allocated; the sum of the activities listed in Line 10 through 19 should be equal to the total number of hours worked noted in Line 9. If No appears in this line, review and revise the appropriate hours. Line 21 Record the number of miles per week that a direct service staff person travels between client sessions. Line 22 Record the number of miles per week that a direct service staff person travels while transporting clients. Staff Training Line 23 Input the number of training hours that direct service staff receive during their first year with your agency. Line 24 Input the average number of training hours that direct service staff annually receive after their first year of employment. Supervision of Direct Care Staff Line 25 Report how many direct care workers are supervised by one supervisor. Line 26 Report the total number of hours a supervisor spends in an average week providing direct supervision to staff.

23 Service Delivery, Groups (For Home and Community-Based services only) KY DMS HCBS Rate Study Cost Survey Instructions Page 21 Line 27 Indicate whether your agency delivers this service to groups (e.g., more than one individual at a time). Line 28 If Line 27 is Yes, indicate the typical group size that receives the service from a single direct service staff.

24 KY DMS HCBS Rate Study Cost Survey Instructions Page 22 C.2 Day Services There are three worksheets for both Day Services: Staff Time, Staffing Patterns, and Group Details. Staff Time The Staff Time forms follow the general instructions discussed previously with the following exceptions related to the Allocation of Time section. If an employee splits their time between administrative and direct care work, only include the portion of their time and salary related to direct care. The Day Services form differentiates between the Adult Day Health and Day Training services in each of the waiver programs. Staffing Patterns These forms collect information on the operation of your agency s Adult Day Health and Day Training programs. For many of these services, the Staffing Patterns form includes separate columns for staff delivering different services, with different qualifications. Specifically: The Day Services form differentiates between Adult Day Health in the ABI, Michelle P. waivers, and Home and Community-Based Waivers. The form also differentiates between the Day Training Services delivered in the Supports for Community Living waiver and those provided in the other waiver programs. Agency Caseload Line 1 Record the number of individuals receiving Adult Day Health and Day Training services from your agency Service Design Line 2 Input the number of days per year that program facilities are open and providing services. Line 3 Input the annual number of days that a typical individual attends the program. Line 4 Input the average number of hours per day the facility is open to provide services. Line 5 Input the number of hours per day that a typical individual receives services. Line 6 Input the total cost of program supplies for your agency s most recently completed fiscal year. Supplies could include, for example, art supplies for a craft project in a Day Treatment and Training program. Line 7 If program supply costs are noted in Line 6, list the types of supplies included in the expense. Line 8 Input the total cost of meals and snack for day programs in your agency s most recently completed fiscal year.

25 KY DMS HCBS Rate Study Cost Survey Instructions Page 23 Line 9 Indicate whether your agency charges members activity fees to participate in certain activities. Line 10 If activity fees are assessed, indicate the average monthly per member fee. Line 11 Input the average monthly cost incurred by the agency for staff to accompany participants to activities Line 12 Please explain the difference between the activity fees and the cost for direct service staff [Lines 10 and 11]. Staffing Pattern This section requests information regarding the typical week for a direct service staff person. The survey lists a number of activities and asks how many hours per week a typical staff person is engaged in each. Line 13 Input the number of hours per week that a single staff person typically works. Line 14 Input the number of hours per week that a staff person is providing direct care. Line 15 Input the number of hours per week that a staff person is participating in Plan of Care (POC) meetings. Line 16 - Input the number of hours per week that a staff person is participating in assessments. Line 17 - Input the number of hours per week that a staff person is transporting individuals from and to their residence and to and from their activity. This figure should reflect the typical time a staff member spends transporting individuals to/from the program. Line 18 - Input the number of hours per week that a direct service staff person spends on recordkeeping activities, other than documentation that occurs during the course of service provision. Line 19 Input the number of hours per week that a staff person is engaged in employer time and not performing direct service duties. Examples include staff meetings, filing employer required paperwork (not related to service delivery), and receiving counseling from a supervisor. Do not include time spent on training programs. Line 20 - Input the number of hours per week that a direct service staff person is performing program development activities, such as developing community relationships to create opportunities for individuals. Line 21 - Input the number of hours per week that a direct service staff person is engaged in set-up and clean-up activities that occur outside of the time when members are present. Lines If there are activities that are part of a staff person s typical week, but not