Instructions for Case Manager Survey

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

Survey Overview Do you have a question concerning the? Navigant will post a list of frequently asked questions to the survey website, found at https://public.navigant.com/sites/wyddsurvey. If the answer to your question is not on that list, you may also email Navigant at wyomingbhd@navigant.com or call 312 251 5926. 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 42 4 120(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. As part of the rate rebasing process, the Division is conducting a survey of case manager costs and wages, and revise the assumptions used for the rate models. Completion of this survey is your opportunity to inform the Division about your operational costs and provide the Division with other information about your agency. This document contains instructions to assist in completing the survey. A case management agency is defined as an organization of multiple case managers or an individual sole proprietor that provides case management services to people with developmental disabilities or acquired brain injury (DD/ABI). Case management services are defined as services to assist participants in gaining access to needed waiver and other Medicaid State Plan services and medical, social, educational and other services regardless of the funding source for the services to which access is gained. This survey should be completed by both case management agencies and individual ( sole proprietor ) case managers who provide case management to participants on the Comprehensive, Supports, and/or ABI waivers. Please note that: If your agency does not maintain financial records sufficient to reliably complete Worksheet C (CM Agency Cost), the Division will still accept the survey with the remaining worksheets completed. 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. Navigant 9/5/2017 Page 1

Survey Overview The survey website provides additional copies of the surveys and corresponding instructions along with a list of frequently asked questions: https://public.navigant.com/sites/wyddsurvey. PLEASE NOTE THAT INDIVIDUALS COMPLETING THIS SURVEY MUST HAVE A WORKING KNOWLEDGE OF AGENCY OPERATIONS AND A THOROUGH UNDERSTANDING OF THE ACCOUNTING RECORDS OF THE ORGANIZATION. Overview The individual schedules included in this Excel based 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. These instructions explain the information that we are seeking on each line item. Note that some questions may pertain to personnel you do not employ; please skip such questions. We request that you provide data as completely and accurately as possible for the case management services that you provide and the personnel you employ. Furthermore, it is important that you fill out each worksheet regardless of whether you are responding as an agency with multiple employees or as an individual case manager. Survey Reporting Time Schedule Please submit the survey to Navigant Consulting by Tuesday, October 10, 2017. Reporting Period The reporting period for this survey be your agency 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, 2016. If you report data on the State s fiscal year, you would report for the period ending June 30, 2017. 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. Navigant 9/5/2017 Page 2

Survey Overview How to Download and Submit the Survey If you did not receive the survey via email, the survey is available in Excel and PDF formats on the survey website https://public.navigant.com/sites/wyddsurvey. The survey is not designed to 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, email 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 email 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, 60606 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 email or mail address. At the close date of the survey submission process, we will identify the survey file most recently received from each 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. How to Complete this Survey if You are an Individual (Sole) Case Manager If you are a self employed and do not have any employees, please complete the survey for one employee (e.g., in Worksheets B and C, you should enter wages for yourself only). When allocating costs, please use your general ledger as much as possible. If you perform functions associated with multiple cost categories (i.e., case management and administration), please split out your time as best you can between the different categories. For example, if your total wages equal $50,000 and you spend 25 percent of your time completing administrative duties, then your administrative payroll costs will equal $12,500. We recommend you track how you spend your time for a week and estimate the percentage of your time spent on case management and administration activities. For more details on the activities that should be included in each cost category, reference the Uniform Chart of Accounts document available on the survey website: https://public.navigant.com/sites/wyddsurvey. Navigant 9/5/2017 Page 3

Survey Overview How to Complete this Survey if Your Organization has Multiple Sites For the purposes of this survey, multiple sites refers to separate office locations. If your agency has multiple provider sites and collects cost data individually for each site, you may choose to submit a separate survey for each site. Collecting cost data separately for each site is particularly helpful if: 1. Your sites are located in different regions of the state, OR 2. Your sites have different sized service areas, for example, Site A serves participants within a 25 mile radius while Site B primarily serves participants living within 50 100 miles, OR 3. Due to other reasons, waiver related costs vary considerably by site. If your agency operates only one site, please provide information about your main office under Location 1 on Worksheet A and skip the questions that ask for information about additional sites. Specific Instructions, by Worksheet The table on the following page provides a description of each of the Worksheets included in the survey. All applicable forms must be completed. Navigant 9/5/2017 Page 4

Survey Overview Table 1: Case Management Cost and Time Survey Worksheets Worksheet A. Case Manager Information B. Case Management Wages and Hours C. Case Management Costs D. Health Insurance Benefits E. Retirement Benefits F. Additional Questions Description General identifying information about the case manager, including locations, service area and total staffing Total case management employee wages and paid hours, broken down by employee type Total costs incurred during the survey period, including employee salaries and wages, program support costs, general & administrative costs and employee related costs by case management agencies Information on health insurance benefits costs and details. Information on retirement benefits, if any, offered by your organization by your employee Breakdown of number of participants by amount of time spent and units billed G. 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 5

Worksheet A: Case Management Agency Information WORKSHEET A: CASE MANAGEMENT AGENCY INFORMATION The purpose of this worksheet is to identify the case management agency and the survey respondent, and to collect information on the provider sites, including number of participants served and service radius. For the purposes of this survey, a case management agency is defined as both an organization that employs two or more case managers and/or other employees, and also as an independent case manager who is self employed. Provider Identification Line 1: Case Manager Name. Enter full name of the case management agency, as submitted on claims billed under the specific Medicaid provider number for which you are responding for this survey. If you are an individual case manager, enter your own name. Line 2: Primary NPI Number. Enter your agency s primary NPI Number. If you are a case manager 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 the city associated with the Medicaid provider number. Line 4: County. Enter the county associated with the Medicaid provider number. Line 5: Case Management Agency Fiscal Year Beginning. Enter the start date (MM/DD/YY) of your agency s most recently completed fiscal year, for example, 01/01/16. This date should be no earlier than January 1, 2016 Line 6: Case Management Fiscal Year Ending. Enter the end date (MM/DD/YY) of your agency s most recently completed fiscal year, for example, 12/31/16. This date should be no later than June 30, 2017 Contact Information Line 7: Contact Person. Enter the name of the person responsible for completing this survey. Line 8: Title. Enter the title of the person responsible for completing this survey. Line 9: Phone Number. Enter the phone number (XXX XXX XXXX) of the person responsible for completing this survey. Line 10: Email Address. Enter email address of person responsible for completing this survey. Navigant 9/5/2017 Page 6

Worksheet A: Case Management Agency Information Provider Locations(s) For each site (office location) that your agency operates, complete the following information: Lines 11, 15, 19: City. Enter the city where the case manager or case management agency is located. Lines 12, 16, 20: County. Enter the county where the case manager or case management agency is located. Lines 13, 17, 21: Number of Waiver Participants Served. Enter the total number of waiver participants served during the provider fiscal year reported in Line 7. For the purposes of this survey, waiver refers to the Comprehensive, Supports and ABI waivers. All other individuals served by you or your agency should be excluded from this calculation (e.g., individuals only receiving TCM and not in the Comprehensive, Supports or ABI waiver programs). Lines 14, 18, 22: Percent of Clients That Live Within. Of the waiver participants served at each provider site during the survey period, indicate the percentage who live within 0 25 miles, 26 50 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. Provider Staffing For Lines 23 and 24, 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. Part time employees are defined as employees working fewer than 30 hours in an average week or 130 hours in an average month. If an employee splits their time between case management and agency administrative responsibilities, please divide that person between Line 23 and 24 (for example,.5 in Line 23 and.5 in Line 24). Note: If you operate multiple sites, enter the total number of other employees across all your sites. Line 23: Total Number of Case Managers. Enter the total number of full time and part time case managers currently employed by your agency. Note: If you operate multiple sites, enter the total number of case managers across all your sites. Line 24: Total Number of Other Employees. Enter the total number of full time and part time employees, other than case managers, currently employed by your organization. Navigant 9/5/2017 Page 7

Worksheet B: Case Manager Wages and Hours WORKSHEET B: CASE MANAGER WAGES AND HOURS This worksheet captures wage and payroll data for case management employees. If your agency has not kept accurate records of these factors, please estimate to the best of your ability. Line Description The lines in this Worksheet represent different employee types. Case Manager Employee Salaries and Wages, Lines 1 through 3 Lines 1 through 3 capture employee wages paid to employees who provided case management services to participants as of August 31, 2017. If you or 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 parttime salaried positions, a reasonable estimate of the number of hours worked over the course of a year. If you or 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 3. If you are an independent case manager, please fill out for your own wages and hours. Column Description Please fill out Columns 1 12, described below, for each case manager type you employ. Hourly Wages 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 8

Worksheet B: Case Manager Wages and Hours 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 2015. 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 2016. 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 2017. 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 2014. Enter the average percent bonus in 2014 given to each employee type, if any. Column 8: Average percent bonus in 2015. Enter the average percent bonus in 2015 given to each employee type, if any. Column 9: Average percent bonus in 2016. 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 employee type 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 9

Worksheet B: Case Manager Wages and Hours 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 10

Worksheet C: Case Management Agency Cost WORKSHEET C: CASE MANAGEMENT AGENCY COSTS The purpose of this worksheet is to report the costs incurred by the case management agency and to determine the waiver program portion of total costs. Note: Only fill out cells that are shaded yellow. Cells shaded white will populate automatically based on what you enter into the yellow cells. Column Descriptions Column 1: Cost Centers 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 Provider Revenues Please see the Line Descriptions section below for further discussion of each cost center under the six major groupings. Colum 2: Uniform Chart of Accounts Code: 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 https://public.navigant.com/sites/wyddsurvey. The corresponding account code from the Uniform Chart of Accounts for each cost center line is listed in Column 2. Column 3: Comprehensive, Supports, and ABI Waivers Enter all costs associated with providing case management under the Comprehensive, Supports, and ABI waivers in Column 3 by cost center. To the extent possible, please exclude any costs that are directly related to providing targeted case management (TCM) such as costs related to medical record requests. For costs accrued in the provision of Navigant 9/5/2017 Page 11

Worksheet C: Case Management Agency Cost waiver case management that do not match the listed cost center descriptions, lines are provided for other expenses within each cost center. Case Managers 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. Columns 4: Other Services Enter all costs not related to providing Comprehensive, Supports, and ABI waiver services in Column 4. Non waiver program costs include the costs of goods and services that are not related to providing case management through Wyoming s DD and ABI Waivers. The following are examples of non waiver program costs, although this list is not all inclusive: Costs related to providing case management services for waivers or programs other than the ABI, Supports or Comprehensive waivers (i.e. the Children s Mental Health Waiver, etc.) Costs related to providing services other than case management (i.e. respite) Costs related to services paid by the State of Wyoming or other governmental agency outside of the Comprehensive, Supports, and ABI 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 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 https://public.navigant.com/sites/wyddsurvey. Column 5: Total Costs This column represents the sum of Column 3 and Column 4. Column 6: Additional Information For Lines 14 16, please check the appropriate box if the costs for vision, dental, and/or life insurance are included in Line 13 (health insurance) because they cannot be broken out separately. Navigant 9/5/2017 Page 12

Worksheet C: Case Management Agency Cost Line Descriptions Salaries and Wages, Lines 1 through 7 Lines 1 through 7 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 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 based on proportions of time spent conducting each type of activity. If you are self employed, estimate your salary/wage amount after you have subtracted your health insurance, payroll taxes and other program related expenses from your gross income amount. Case Management Employee Salaries and Wages, Lines 1 through 4 These cost center lines capture program employee total gross salaries and wages paid and accrued, including bonuses, by employee category. Case Management Employee Salaries and Wages are defined as costs associated with employees who provide direct support for participants. This includes case managers and case manager supervisors. If your Case Manager Supervisors also conduct other activities (e.g., direct case management or administration), please allocate their wages according to the approximate time spent on each type of activity. Enter amounts, by employee category, on Lines 1 through 2. Enter amounts for other case management employees (e.g., clerical assistants who provide direct support to case managers) on Line 3 and a description of the expense in Column 1. The survey will automatically sum Lines 1 through 3 on Line 4. As such, do not enter data into this line. Administration Employee Salaries and Wages, Line 5 Enter administration employees salaries and wages on Line 5. This cost center captures administration employee total gross salaries and wages, including bonuses. Administration Employee Salaries and Wages are defined as costs associated with employees who provide management, accounting, information technology and human resource services inside of the case management agency. If administrative services are provided at a central corporate office outside of the agency s principal place of business, Navigant 9/5/2017 Page 13

Worksheet C: Case Management Agency Cost then enter the allocated portion of administrative employee salaries and wages applicable to the local level. Other Employee Salaries and Wages, Line 6 Enter total gross salaries and wages paid to all other employees and the value of any donated services in this total on Line 6. The survey will automatically sum Lines 4, 5 and 6 on Line 7, Total Salaries and Wages. As such, do not enter data into this line. Employee Taxes, Insurance and Benefits, Lines 8 through 23 Lines 8 through 23 capture costs incurred by the 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 Salaries and Wages cost center lines). Employee Payroll Taxes, Lines 8 through 11 These cost center lines capture the employer s portion of any FICA, FUI, SUI, and other payroll related taxes. It also includes the employer s portion of premiums paid and accrued for the state workers compensation fund or other workers compensation insurance plan. The survey will automatically sum Lines 8 through 11 on Line 12. As such, do not enter data into this line. Employee Insurance, Lines 13 through 20 These cost center lines capture the employer s portion of any costs related to employee health insurance, dental insurance, life insurance and disability insurance. If an agency is self insured, only include the cost of actual claims paid or accrued. Enter amounts, by category, on Lines 13 through 20. Enter total employee insurance cost on Line 20 only if employee insurance expenses at the detail level are not available. Amounts reported on Lines 18 and 19 must be accompanied by a description of reported costs. The survey will automatically enter the sum of Lines 13 through 19 on Line 20. Do not enter data into Line 20. Navigant 9/5/2017 Page 14

Worksheet C: Case Management Agency Cost Employee Other Benefits, Lines 21 through 23 This cost center line captures the employer s costs related to retirement and any other employee benefits not recorded elsewhere in Lines 21 and 23. Enter the employer s portion of any costs related to employee retirement programs on Line 21. These costs could include employer contributions to pension plans, employer contributions to 401k plans, or other retirement related programs. Any other benefits costs not reported on Line 21 must be reported on Line 22. Enter a description of these other benefits costs in Column 1. The survey will automatically sum Lines 21 and 22 on Line 23. Do not enter data into this line. The survey will automatically enter the sum of Lines 12, 20, and 23 on Line 24 (Total Employee Taxes, Insurance and Benefits). As such, do not enter data into this line. Contracted Services, Lines 25 through 28 Lines 25 through 28 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 case management agency. Contracted Program Services, Line 25 This cost center line captures expenditures for contracted program services. Contracted program services are provided by the same types of employee categories listed on lines 1 through 3, e.g., case managers, case manager supervisors and other case manager employees. It is important to note that contracting case management services is not allowed by the Division. However, if you contract out other program services, such as respite, please enter that information here. Contracted Administration Services, Line 26 This cost center line captures expenditures for contracted administration services for management, clerical support, information technology support, accounting, professional service fees, legal expenses/attorney fees or other contracted administration services. Navigant 9/5/2017 Page 15

Worksheet C: Case Management Agency Cost Contracted Maintenance Services, Line 27 This cost center line captures expenditures for contracted maintenance services. Enter total amount spent on contracted maintenance services on line 27. The survey will automatically sum Lines 25 26 and 27 on Line 28 (Total Contracted Services). As such, do not enter data into this line. Non Payroll Administration Expenses, Lines 29 through 33 Lines 29 through 32 capture administration expenses not relating to payroll. Only the portion paid and accrued by the agency must be reported on these lines. Administration Expenses, Line 29 This cost center line captures expenditures for non payroll related administrative services, including advertising, bank service charges/fees, office supplies, information technology, postage, printing and publishing, other administrative expenses related to your Central Office, fundraising activities, meeting expenses and membership dues. Do not report the costs associated with contracted services (these costs must be reported in the appropriate contracted services cost center lines). Licenses/Taxes, Line 30 This cost center line captures non payroll taxes incurred by the agency, including ad valorem property taxes, State and federal taxes and Vehicle licenses and registration expenses. If your agency is based out of a home office, please refer to the IRS website for a description of the home office deduction: http://www.irs.gov/businesses/small Businesses & Self Employed/Home Office Deduction Liability and Other Insurance, Line 31 This cost center line captures expenditures for liability and other agency insurance. This line includes, for example, general liability expenses, directors and officers insurance, professional malpractice expenses and buildings, contents and grounds insurance expenses and vehicle related insurance costs. It should be noted that the Division does not require case managers to carry such insurance. Navigant 9/5/2017 Page 16

Worksheet C: Case Management Agency Cost Non Payroll Related Personnel Expenses, Line 32 This cost center line captures all non payroll expenditures for employees, including costs relating to hiring and training workers. This line includes, for example, the nonpersonnel costs of background check and drug testing, non personnel costs of recruitment, and the non personnel costs of training related to the provision of consumer care. Do not report the payroll costs associated with time spent participating in training (these costs must be reported in the appropriate salaries and wages category). The survey will automatically sum Lines 29 through 32 on Line 33, Total Non Payroll Administration Expenses. As such, do not enter data into this line. Non Payroll Program Support Expenses, Lines 34 through 37 Lines 34 through 37 capture non payroll expenditures made for the support of client programs. Supplies, Line 34 These cost center lines capture expenditures for materials used in participant care or programs support services. Transportation, Lines 35 through 36 These cost center lines capture the costs of transportation, including service related transportation and transportation reimbursements made to program staff. This includes purchased transportation services, fuel expenses and mileage reimbursements paid to 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 35. Transportation costs include fuel expenses and mileage reimbursements made to program staff for transportation 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. Navigant 9/5/2017 Page 17

Worksheet C: Case Management Agency Cost Enter non service related transportation expenses on Line 36. 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 35 and 36 on Line 37. Do not enter data into this line. Facility, Vehicle and Equipment Related Expenses, Lines 38 through 42 Lines 38 through 42 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 Expenses, Line 38 This cost center line captures rental and property expenses related to facilities, vehicles and equipment, by category. Include the following expenses: Building rental/lease Facility related interest Facility related equipment rental/lease Vehicle rental/lease Vehicle related interest expense Interest expense on working capital 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 3. Maintenance and Repairs, Line 39 This cost center line captures all non payroll maintenance and repair expenses related to facilities, vehicles and equipment, by category. Depreciation and Amortization, Line 40 This cost center line captures depreciation for provider owned facilities, vehicles and equipment. For the purposes of this survey, depreciation is defined as the reduction in the value of an asset with the passage of time; and amortization is defined as the paying off of a debt with a fixed repayment schedule in regular installments over a period of time (i.e. a car payment). Case Managers must submit, along with the survey, a Navigant 9/5/2017 Page 18

Worksheet C: Case Management Agency Cost 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 case manager may set a lower capitalization threshold if it does not materially affect reported costs. Utilities, Line 41 This cost center line captures expenses related to utilities and disposal services. All costs related to internet service should be included here, not as an administration costs. The survey will also automatically sum Lines 7, 24, 28, 33, 37 and 42 on Line 43 (Grand Totals). As such, do not enter data into this line. Please provide additional information needed to explain your reported costs, Line 44. Please use this line to convey any additional information that you might feel necessary to explain your reported costs, such as the mileage traveled on a regular basis or mileage reimbursement rates paid to employees. Case Manager Revenues, Lines 45 through 48 Note: If you operate multiple sites, enter total revenues earned across all your sites. Line 45: Total Case Management Revenue for Comprehensive, Supports, and ABI Waivers. Total revenues, as recorded in the case management agency s general ledger, earned from Medicaid payments for Comprehensive, Supports, and ABI waiver case management services provided during the survey period. Line 46: Total TCM Revenue. Total revenues, as recorded in the case management agency s general ledger, earned for providing TCM services during the survey period. Line 47: Total Other Case Management Revenues. Total revenues, as recorded in the case management agency s general ledger, earned from other case management activities that are not reimbursed through the Comprehensive, Supports, and ABI waivers or through TCM, if applicable. Navigant 9/5/2017 Page 19

Worksheet C: Case Management Agency Cost Line 48: Total Other Service Revenues. Total revenues, as recorded in the case manager s general ledger, earned from any non case management services rendered during the survey period, for example, any revenues earned from direct services, such as respite. Line 49: Total Revenues. Automatically Calculated. Total revenues for the survey period as recorded in the case management agency s general ledger. Navigant 9/5/2017 Page 20

Worksheet D: Employee Health Insurance Benefits WORKSHEET D: 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 21

Worksheet E: Employee Retirement Benefits WORKSHEET E: 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 22

Worksheet F: Additional Case Management Questions WORKSHEET F: ADDITIONAL 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 you or your agency under each waiver. Include Child DD waiver participants under whichever waiver they will transition to in the future. 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 23

Worksheet F: Additional Case Management Questions Supplemental Information Units Line 7: Monthly Rate Unit. Please enter the total number of participants for whom you bill for services using the monthly rate unit. Line 8: 15 Minute Rate Unit. Please enter the total number of participants for whom you bill for services using the 15 minute rate unit. Note: the sum of Lines 7 and8 should equal the value entered in Line 1 for each column. Navigant 9/5/2017 Page 24

Worksheet G: Error Check WORKSHEET G: ERROR CHECK To finalize the survey once you have entered data, go to Worksheet F and respond to each of the questions listed by worksheet. If your response is Yes then place an X in the Yes column (Column 3). If your response is No (meaning there is a potential error), please correct your response so that you are able to answer Yes. If you are unable to resolve an issue prior to the survey submission due date, please submit your survey regardless and place an X in the No Column (Column 4). We may follow up with you regarding any places where your response is No. Navigant 9/5/2017 Page 25