Wyoming

In 2008, the Department of Health was required by state statute (W.S. 42-4-120 (g)) to establish a cost-informed reimbursement system to pay providers of services and supplies under home and community based waiver programs for persons with developmental disabilities or acquired brain injury. This state statute also required that rates be rebased at least once every four (4) years, but not more than once in any two (2) year period. As Wyoming’s state statute requires a cost-informed rate methodology, provider cost surveys are collected to inform the rate model. The State Medicaid Agency may adjust rates as directed by the state legislature or Governor in order to balance the State’s budget. The Home and Community Based Services Section in the Department of Health’s Division of Healthcare Financing is responsible for rate determination and oversight of the rate determination process, and directs the issuance and analysis of provider cost surveys, analysis of publicly available data, development or updating of rate models, and other activities as part of the rate determination process with contractor input within the statutorily required timeframe.

The Department of Health contracted a rate study for Wyoming’s (HCBS) waivers in 2020-2021.

The Department and its contractor worked with key stakeholders from April 2020 to December 2021 to conduct the rate study and develop proposed waiver program rates. Stakeholder involvement included the following workgroups:

Provider Team – Composed of small and large providers and case management agencies who reviewed the survey design and materials, gave input on rate component assumptions, and developed related recommendations for consideration by the Steering Committee.

Steering Committee – Composed of key state agency staff, legislators, and consumer and provider representatives who reviewed and selected key rate assumptions based on contractor-developed materials and recommendations from the Provider Team.

Rate Components: An independent rate build-up methodology based on cost and wage data from providers and other state and national data sources was used. The independent rate build-up methodology comprises direct care and indirect care components and uses assumptions about types of employees; wage rates; benefits; program support and administration costs; supervisor span of control; staffing patterns; and direct care work productivity factors. Some components vary between services while others are the same across the services. This rate determination methodology was used to calculate rates for the following services:

* Adult Day – all levels

* Behavioral Support – all levels

* Case Management

* Child Habilitation

* Cognitive Retraining

* Community Living – all levels

* Community Support – all levels

* Companion

* Crisis Intervention

* Individual Habilitation Training

* Personal Care

* Respite

* Special Family Habilitation Home

* Supported Employment

* Transportation

The Department of Health distinguishes between “agency providers” and “independent providers” for some services, with varying rates based on differences in indirect costs incurred by the two provider types. Independent providers are defined as providers that do not designate wage rates and do not employ staff members other than themselves. Analysis during the rate study determined that administrative costs are significantly lower for independent providers than agency providers. Reimbursement rates for independent providers reflect reduced administrative cost assumptions for these providers.

Direct Care Cost Rate Components:

Staff Wages: For the direct care worker wage, the BLS occupational category of Home Health and Personal Care Aides (BLS category: 31-1120) was used as the wage benchmark. This benchmark was also used for job coaches and vocational trainers. Effective September 1, 2022 DHCF used CMS Market Basket data, which were inflated to the midpoint of SFY 2023, to a limit established by projections of available funding in order to support retention of experienced, skilled staff for services tiered to deliver care to individuals with high resource needs. BLS wages for Maids and Housekeeping Cleaners (37-2012) were used for homemaker services, and Rehabilitation Counselor (BLS occupational category 21-1015) was used to identify the wage for rehabilitation counselors. Shift and unit supervisors were benchmarked to First Line Supervisors of Personal Service Workers (39-1022); registered behavioral technicians to Psychiatric Technicians (29-2053); behavior analysts to Clinical, Counseling and School Psychologists (19-3031); and assistant behavior analysts to Counselors, All Other (21-1019). Case managers were benchmarked to a blended wage based on 50% Healthcare Social Workers (21-1022) and 50% Child, Family, and School Social Workers (21-1021). All wage data were inflated to the midpoint of SFY 2023 using CMS Market Basket data .

Employee Related Expense (ERE) Factor:

The ERE factor reflects the cost of program employee benefits, specifically: federally required benefits such as FICA, FUTA, SUTA, and workers compensation; health and dental insurance; retirement benefits; and long- and short-term disability benefits.

Health insurance costs were identified using the Medical Expenditure Panel Survey (MEPS) average employer portion (Wyoming 2019 MEPS Table) with an inflation factor added to update insurance costs to the midpoint of SFY 2023 based on CMS Market Basket data. Retirement benefit costs were calculated using BLS data reported on retirement costs as a percent of salary and wages for private industry health care and social assistance “service” workers. Federally required benefits were calculated using national and state percentages, and additional benefits were based on provider cost report data.

Full Time Equivalent (FTE) Factor:

The FTE factor represents costs associated with payroll hours required to cover for staff when they are not available to provide direct services (i.e., vacation days, sick time, training). Approximately 22 days per year were included for the FTE factor based on the average number of paid time off and paid training hours per employee reported in the provider cost and wage surveys.

Productivity Adjustment: The rate model includes service-specific productivity factors to account for non-face-to-face time necessary to deliver services (planning, meetings, recordkeeping, etc.). The Provider Team provided productivity factor recommendations to the Steering Committee based on provider experience, service requirements and a review of the productivity factors used in the SFY 2019 study. The proposed factors were reviewed and any changes that were needed were made based on service requirements.

Indirect Care Cost Rate Components

Administration Factor: The administration factor reflects costs associated with operating a provider agency. These costs include: administrative employees’ salaries, office supplies and services, information technology expenses, central corporate office other administration expenses allocated to the local level, licenses/taxes, liability and other insurance, background checks, and non-service related transportation. Provider cost data specific to non-case management service providers was used to calculate an administrative factor representing approximately 6 to 22 percent of the rate (varies by service).

Program Support Factor: The program support factor reflects the costs that support direct care services, such as non-payroll program support costs, non-payroll facility, vehicle and equipment expenses, maintenance costs, and program supplies. The Program Support Factor was tailored by service to reflect whether service provision required facility and/or vehicle costs. Costs related to room and board for participants including facility maintenance, upkeep, and improvement related to community living (residential) program services were excluded from the total costs collected for the rate determination. Additionally, cost outliers from provider costs and wage surveys were excluded and the program support portion of the rate for community living services was capped at the level 4 amount. Program support factors vary by service and range from 6 to 18 percent of the rate. Transportation services are calculated without a program support factor as the program support portion of the rate is provided through the mileage payment adjustment.

Skilled Nursing and assessment; Dietician; Occupational Therapy; Physical Therapy; Speech, Hearing and Language services were not included in the updated rate methodology. These rates shall be based on the rates paid through the Medicaid State Plan.

Due to the variable nature of some services, services consisting of equipment purchase and installation are reimbursed at the cost to the provider rather than a standardized reimbursement rate. Case managers must obtain at least two competitive bids for environmental modification and specialized equipment services. Payment is authorized to the provider with the most cost-effective bid which meets the needs of the participant. The Service Index and Fee Schedule for all services can be found on the Department’s website .

For self-directed services, the participant does not utilize the provider-managed rate methodology. Instead, s/he pays staff a wage that covers the needed services and can be paid within his/her IBA. The cost to the participant’s IBA is the wage, which includes employer payroll taxes, state and federal unemployment taxes. The participant may increase the wage to assist with employee medical benefits. The wage minimum is based upon the federal minimum wage and the wage maximum is based upon what the IBA will support.

Participants using self-directed services are assigned an IBA using the same methodology as participants who don’t self-direct. When services receive rate increases, the budget methodology is updated so participants maintain the same purchasing power to include the IBA given to participants using self-directed services.

The Case Management – Certificate rate includes a 5% incentive above the base rate to account for the expertise the case manager gains by completing the Division sponsored training that addresses person-centered planning and case management best practices.

Participants are notified of the rates through email. Case managers are notified about the specific details of all rate changes and are required to notify the participant of the changes, discuss how the changes may impact the participant, and address any questions or concerns the participant may have. For information on how the state solicits public comment on rate determination methods refer to Main Section 6-I.

The Service Index and Fee Schedule for all services can be found at https://health.wyo.gov/healthcarefin/hcbs/services-regulations/.

In 2008, the Department of Health was required by state statute (W.S. 42-4-120 (g)) to establish a cost-informed reimbursement system to pay providers of services and supplies under home and community based waiver programs for persons with developmental disabilities or acquired brain injury. This state statute also required that rates be rebased at least once every four (4) years, but not more than once in any two (2) year period. As Wyoming’s state statute requires a cost-informed rate methodology, provider cost surveys are collected to inform the rate model. The State Medicaid Agency may adjust rates as directed by the state legislature or Governor in order to balance the State’s budget. The Home and Community Based Services Section in the Department of Health’s Division of Healthcare Financing is responsible for rate determination and oversight of the rate determination process, and directs the issuance and analysis of provider cost surveys, analysis of publicly available data, development or updating of rate models, and other activities as part of the rate determination process with contractor input within the statutorily required timeframe.

The Department of Health contracted a rate study for Wyoming’s (HCBS) waivers in 2020-2021.

The Department and its contractor worked with key stakeholders from April 2020 to December 2021 to conduct the rate study and develop proposed waiver program rates. Stakeholder involvement included the following workgroups:

Provider Team – Composed of small and large providers and case management agencies who reviewed the survey design and materials, gave input on rate component assumptions, and developed related recommendations for consideration by the Steering Committee.

Steering Committee – Composed of key state agency staff, legislators, and consumer and provider representatives who reviewed and selected key rate assumptions based on contractor-developed materials and recommendations from the Provider Team.

Rate Components:

An independent rate build-up methodology based on cost and wage data from providers and other state and national data sources was used. The independent rate build-up methodology comprises direct care and indirect care components and uses assumptions about types of employees; wage rates; benefits; program support and administration costs; supervisor span of control; staffing patterns; and direct care work productivity factors. Some components vary between services while others are the same across the services. This rate determination methodology was used to calculate rates for the following services:

• Adult Day Services

• Behavioral Support Services

• Case Management

• Child Habilitation Services

• Cognitive Retraining

• Community Living Services

• Community Support Services

• Companion Services

• Crisis Intervention Support

• Homemaker Services

• Individual Habilitation Training

• Personal Care Services

• Respite

• Supported Employment

• Transportation Services

The Department of Health distinguishes between “agency providers” and “independent providers” for some services, with varying rates based on differences in indirect costs incurred by the two provider types. Independent providers are defined as providers that do not designate wage rates and do not employ staff members other than themselves. Analysis during the rate study determined that administrative costs are significantly lower for independent providers than agency providers. Reimbursement rates for independent providers reflect reduced administrative cost assumptions for these providers.

Direct Care Cost Rate Components:

Staff Wages: For the direct care worker wage, the BLS occupational category of Home Health and Personal Care Aides (BLS category: 31-1120) was used as the wage benchmark. This benchmark was also used for job coaches and vocational trainers. Effective September 1, 2022 DHCF used CMS Market Basket data, which were inflated to the midpoint of SFY 2023, to a limit established by projections of available funding in order to support retention of experienced, skilled staff for services tiered to deliver care to individuals with high resource needs. BLS wages for Maids and Housekeeping Cleaners (37-2012) were used for homemaker services, and Rehabilitation Counselor (BLS occupational category 21-1015) was used to identify the wage for rehabilitation counselors. Shift and unit supervisors were benchmarked to First Line Supervisors of Personal Service Workers (39-1022); registered behavioral technicians to Psychiatric Technicians (29-2053); behavior analysts to Clinical, Counseling and School Psychologists (19-3031); and assistant behavior analysts to Counselors, All Other (21-1019). Case managers were benchmarked to a blended wage based on 50% Healthcare Social Workers (21-1022) and 50% Child, Family, and School Social Workers (21-1021). All wage data were inflated to the midpoint of SFY 2023 using CMS Market Basket data .

Employee Related Expense (ERE) Factor:

The ERE factor reflects the cost of program employee benefits, specifically: federally required benefits such as FICA, FUTA, SUTA, and workers compensation; health and dental insurance; retirement benefits; and long- and short-term disability benefits.

Health insurance costs were identified using the Medical Expenditure Panel Survey (MEPS) average employer portion (Wyoming 2019 MEPS Table) with an inflation factor added to update insurance costs to the midpoint of SFY 2023 based on CMS Market Basket data. Retirement benefit costs were calculated using BLS data reported on retirement costs as a percent of salary and wages for private industry health care and social assistance “service” workers. Federally required benefits were calculated using national and state percentages, and additional benefits were based on provider cost report data.

Full Time Equivalent (FTE) Factor:

The FTE factor represents costs associated with payroll hours required to cover for staff when they are not available to provide direct services (i.e., vacation days, sick time, training). Approximately 22 days per year were included for the FTE factor based on the average number of paid time off and paid training hours per employee reported in the provider cost and wage surveys.

Productivity Adjustment: The rate model includes service-specific productivity factors to account for non-face-to-face time necessary to deliver services (planning, meetings, recordkeeping, etc.). The Provider Team provided productivity factor recommendations to the Steering Committee based on provider experience, service requirements and a review of the productivity factors used in the SFY 2019 study. The proposed factors were reviewed and any changes that were needed were made based on service requirements.

Indirect Care Cost Rate Components

Administration Factor: The administration factor reflects costs associated with operating a provider agency. These costs include: administrative employees’ salaries, office supplies and services, information technology expenses, central corporate office other administration expenses allocated to the local level, licenses/taxes, liability and other insurance, background checks, and non-service related transportation. Provider cost data specific to non-case management service providers was used to calculate an administrative factor representing approximately 6 to 22 percent of the rate (varies by service).

Program Support Factor: The program support factor reflects the costs that support direct care services, such as non-payroll program support costs, non-payroll facility, vehicle and equipment expenses, maintenance costs, and program supplies. The Program Support Factor was tailored by service to reflect whether service provision required facility and/or vehicle costs. Costs related to room and board for participants including facility maintenance, upkeep, and improvement related to community living (residential) program services were excluded from the total costs collected for the rate determination. Additionally, cost outliers from provider costs and wage surveys were excluded and the program support portion of the rate for community living services was capped at the level 4 amount. Program support factors vary by service and range from 6 to 18 percent of the rate. Transportation services are calculated without a program support factor as the program support portion of the rate is provided through the mileage payment adjustment.

Skilled Nursing and assessment; Dietician; Occupational Therapy; Physical Therapy; Speech, Hearing and Language services were not included in the updated rate methodology. These rates shall be based on the rates paid through the Medicaid State Plan.

Due to the variable nature of some services, services consisting of equipment purchase and installation are reimbursed at the cost to the provider rather than a standardized reimbursement rate. Case managers must obtain at least two competitive bids for environmental modification and specialized equipment services. Payment is authorized to the provider with the most cost-effective bid which meets the needs of the participant. The Service Index and Fee Schedule for all services can be found on the Department’s website .

For self-directed services, the participant does not utilize the provider-managed rate methodology. Instead, s/he pays staff a wage that covers the needed services and can be paid within his/her IBA. The cost to the participant’s IBA is the wage, which includes employer payroll taxes, state and federal unemployment taxes. The participant may increase the wage to assist with employee medical benefits. The wage minimum is based upon the federal minimum wage and the wage maximum is based upon what the IBA will support.

Participants using self-directed services are assigned an IBA using the same methodology as participants who don’t self-direct. When services receive rate increases, the budget methodology is updated so participants maintain the same purchasing power to include the IBA given to participants using self-directed services.

The Case Management – Certificate rate includes a 5% incentive above the base rate to account for the expertise the case manager gains by completing the Division sponsored training that addresses person-centered planning and case management best practices.

Participants are notified of the rates through email. Case managers are notified about the specific details of all rate changes and are required to notify the participant of the changes, discuss how the changes may impact the participant, and address any questions or concerns the participant may have. For information on how the state solicits public comment on rate determination methods refer to Main Section 6-I.

The Service Index and Fee Schedule for all services can be found at https://health.wyo.gov/healthcarefin/hcbs/services-regulations/.