1. PROVIDER IDENTIFICATION
1 PROVIDER NAME:
2
3 CITY:
4 COUNTY:
5 CARF CERTIFICATION STATUS:
6 PROVIDER FISCAL YEAR BEGINNING:
7 PROVIDER FISCAL YEAR ENDING:
8 CONTACT PERSON:
9 TITLE:
10 PHONE NUMBER:
11 EMAIL ADDRESS:
3. PROVIDER SITES
SITE 1
12 CITY
13 COUNTY
14
PERCENT OF PARTICIPANTS THAT LIVE:
0-25 MILES FROM LOCATION
26-50 MILES FROM LOCATION
GREATER THAN 50 MILES FROM LOCATION
SITE 2
16 CITY
17 COUNTY
18
PERCENT OF PARTICIPANTS THAT LIVE WITHIN:
0-25 MILES FROM LOCATION
26-50 MILES FROM LOCATION
GREATER THAN 50 MILES FROM LOCATION
Yes
NUMBER OF WAIVER PARTICIPANTS SERVED DURING
PROVIDER FISCAL YEAR (ENTERED ABOVE)
NUMBER OF WAIVER PARTICIPANTS SERVED DURING
PROVIDER FISCAL YEAR (ENTERED ABOVE)
2. CONTACT INFORMATION
XXX-XXX-XXXX
INSTRUCTIONS:
This survey should be completed by waiver providers with a $1,000,000 or more in SFY 2016 waiver revenues who have a NPI number.
The survey website provides additional copies of the survey along with a list of frequently asked questions:
https://public.navigant.com/sites/wyddsurvey. Providers earning less than $1,000,000 are asked to fill out a separate wage survey, but are
welcome to fill out the “full” cost and wage survey if they are able. Providers that do not designate wage rates do not need to complete a
survey; these are providers that do not have a business tax identification number, or used their social security number as a business tax
identification number. There is a separate survey for case management agencies.
Providers should use data from their most recent fiscal year unless otherwise noted (i.e., FYE 12/31/2016 or 6/30/2017).
Providers with multiple locations/sites are encouraged to submit one survey that encompasses data for all of their locations/sites; however,
providers may choose to submit a separate survey for each location/site if necessary.
15
19
Provider Name
XXXXXXPRIMARY NPI NUMBER:
City
County
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
Ms. Doe
Chief Financial Officer
WORKSHEET A: PROVIDER INFORMATION
Navigant -- 9/5/2017 1
INSTRUCTIONS:
This survey should be completed by waiver providers with a $1,000,000 or more in SFY 2016 waiver revenues who have a NPI number.
The survey website provides additional copies of the survey along with a list of frequently asked questions:
https://public.navigant.com/sites/wyddsurvey. Providers earning less than $1,000,000 are asked to fill out a separate wage survey, but are
welcome to fill out the “full” cost and wage survey if they are able. Providers that do not designate wage rates do not need to complete a
survey; these are providers that do not have a business tax identification number, or used their social security number as a business tax
identification number. There is a separate survey for case management agencies.
Providers should use data from their most recent fiscal year unless otherwise noted (i.e., FYE 12/31/2016 or 6/30/2017).
Providers with multiple locations/sites are encouraged to submit one survey that encompasses data for all of their locations/sites; however,
providers may choose to submit a separate survey for each location/site if necessary.
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
WORKSHEET A: PROVIDER INFORMATION
SITE 3
20 CITY
21 COUNTY
22
PERCENT OF PARTICIPANTS THAT LIVE:
0-25 MILES FROM LOCATION
26-50 MILES FROM LOCATION
GREATER THAN 50 MILES FROM LOCATION
SITE 4
24 CITY
25 COUNTY
26
PERCENT OF PARTICIPANTS THAT LIVE:
0-25 MILES FROM LOCATION
26-50 MILES FROM LOCATION
GREATER THAN 50 MILES FROM LOCATION
28 Are you completing this survey for a particular site?
29 If yes, please indicate the relevant site (from above).
4. PROVIDER STAFFING
30
31
NUMBER OF WAIVER PARTICIPANTS SERVED DURING
PROVIDER FISCAL YEAR (ENTERED ABOVE)
NUMBER OF WAIVER PARTICIPANTS SERVED DURING
PROVIDER FISCAL YEAR (ENTERED ABOVE)
TOTAL NUMBER OF FULL-TIME EMPLOYEES AT END OF
PROVIDER FISCAL YEAR
(30 or more hours/week or 130 hours/month)
27
If your organization has multiple provider sites and collects cost data individually for each site, you may choose to submit to
information for each site using separate surveys.
23
TOTAL NUMBER OF PART-TIME EMPLOYEES AT END OF
PROVIDER FISCAL YEAR
(Less than 30 hours/week or 130 hours/month)
Navigant -- 9/5/2017 2
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE:
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
WORKSHEET B: SERVICES PROVIDED BY AGENCY
Check all that apply.
Adult Day Services Personal Care
Behavioral Support Services Physical Therapy
Case Management Prevocational
Child Habilitation Services Residential Habilitation Host Homes
Community Integration Services Residential Habilitation Services
Companion Services Respite
Cognitive Retraining Self-Directed Goods
Crisis Intervention Support Skilled Nursing
Dietician Special Family Habilitation Home
Employment Discovery and Customization Speech, Language and Hearing Services
Environmental Modification Supported Employment
Homemaker Supported Employment Follow Along
Independent Support Broker Supported Living
Individual Habilitation Training Transportation Services
Occupational Therapy
Note: Definitions of each service area may be found on the Wyoming Department of Health website, specifically:https://health.wyo.gov/wp-content/uploads/2016/06/BHD-Service-Index-Revised-2.27.17.pdf
Please specify: all sites or a specific site
Navigant -- Draft -- 8/25/2017 3
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
Program Employee Salaries and Wages
1 Direct Care Workers 5010 -
2 Direct Care Trainers 5020 -
3 Shift and Unit Supervisors 5030 -
4 Case Managers 5040 -
5 Job Coaches and Vocational Trainers 5050 -
6 Dieticians 5060 -
7 Nurses 5070 -
8 Psychiatrists 5080 -
9 Psychologists 5090 -
10 Physical Therapists 5100 -
11 Occupational Therapists 5110 -
12 Speech Therapists 5120 -
13 Other Program Employees 5130 -
14 Total Program Employee Salaries and Wages - - -
(Specify)
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers
SALARIES AND WAGES
Additional Information
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 4
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
15
5210-5240 -
Maintenance Employee Salaries and Wages
16 Maintenance Staff -- Vehicle 5310 -
17 Maintenance Staff -- All Other 5320-5340 -
18 Total Maintenance Employee Salaries and Wages - - -
Administration Employee Salaries and Wages
19 Administrator/CEO/Director 5410 -
20 Assistant Administrator/Director 5420 -
21 Employee Owners, Partners or Stockholders 5430 -
22 Board Member Compensation 5440 -
23 Administrative Staff (e.g., professional/clerical/IT staff) 5450-5470 -
24 Central Corporate Office Administration Staff Allocated to Local Level 5480 -
25 Fundraising Activity Personnel 5490 -
26 Other Administration Employee 5500 -
27 Total Administration Employee Salaries and Wages - - -
(Specify)
Program Support Employee Salaries and Wages
(e.g., program coordinators, quality assurance/data analysts, food/housekeeping staff) Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 5
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
Client and Other Salaries and Wages
28 Client Salaries and Wages 5610 -
29 Donated Services 5620 -
30 Other Salaries and Wages 5630 -
31 Total Client and Other Salaries and Wages - - -
32 - - -
Employee Payroll Taxes
33 FICA 5710 -
34 FUI 5720 -
35 SUI 5730 -
36 Workers Compensation and Other Payroll Taxes 5740-5750 -
37 Total Employee Payroll Taxes - - -
(Specify)
EMPLOYEE TAXES, INSURANCE AND BENEFITS
TOTAL SALARIES AND WAGES
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 6
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
Employee Insurance
38 Employee Health Insurance 5810 -
39 Employee Vision Insurance 5860 -
40 Employee Dental 5820 -
41 Employee Life Insurance 5830 -
42 Employee Short-Term and Long-Term Disability Insurance 5840 -
43 Client Fringe Benefits 5850 - 44 Other Employee Insurance, excluding any categories listed above 5860 -
45 Total Employee Insurance - - -
Employee Other Benefits
46 Retirement 5910 -
47 Other Benefits 5920 -
48 Total Employee Other Benefits - - -
49 - - -
(Specify)
(Specify)
(Specify)
TOTAL EMPLOYEE TAXES, INSURANCE AND BENEFITS
Costs are included in Line 38; not possible to break out separately
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Costs are included in Line 38; not possible to break out separately
Costs are included in Line 38; not possible to break out separately
Navigant -- 9/5/2017 7
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
Contracted Program Services
50 Direct Care Workers Contracted Program Services 6010 -
51 Direct Care Trainers Contracted Program Services 6020 -
52 Contracted Shift and Unit Supervisor 6030 -
53 Case Managers Contracted Program Services 6040 -
54 Job Coaches and Vocational Trainers Contracted Program Services 6050 -
55 Dieticians Contracted Program Services 6060 -
56 Nurses Contracted Program Services 6070 -
57 Psychiatrists Contracted Program Services 6080 -
58 Psychologists Contracted Program Services 6090 -
59 Physical Therapists Contracted Program Services 6100 -
60 Occupational Therapists Contracted Program Services 6110 -
61 Speech Therapists Contracted Program Services 6120 -
62 Other Contracted Program Employees 6130 -
63 Total Contracted Program Services - - -
(Specify)
CONTRACTED SERVICES
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 8
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
64 Contracted Maintenance Services (e.g., vehicle/equipment/plant) 6210-6240 -
65 Contracted Administration Services 6310-6360 -
66 - - -
Administration Expenses
67 Advertising 6710 -
68 Bank Service Charges / Fee 6720 -
69 CARF Survey 6730 -
70 Office Supplies and Services (e.g., office supplies/postage/shipping/printing) 6740-6760 -
71 Information Technology Expenses 6770 -
72 Central Corporate Office Other Administration Expenses Allocated to Local Level 6780 -
73 Dues, Memberships and Subscriptions 6790 -
74 Fundraising Activities 6800 -
75 Other Administrative Expenses (e.g., meeting expenses, etc.) 6820 -
76 Total Administration Expenses - - -
(Specify)
TOTAL CONTRACTED SERVICES
NON-PAYROLL ADMINISTRATION EXPENSES
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 9
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
77 Licenses/Taxes 7010-7030 -
Liability and Other Insurance
78 Vehicle Related Insurance 7150 -
79 All Other Insurance 7110-7140, 7160 -
80 Total Liability and Other Insurance - - -
Non-Payroll Related Personnel Expenses
81 Background Checks / Drug Testing 6610 -
82 Recruitment 6620 -
83 Training 6630 -
84 Other Non-Payroll Personnel Expenses 6640 -
85 Total Non-Payroll Related Personnel Expenses - - -
86 - - -
(Specify)
TOTAL NON-PAYROLL ADMINISTRATION EXPENSES
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 10
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
87 Supplies (related to materials used in client care or program support services) 6510-6590 -
Transportation
88 6910 -
89 Transportation/Travel - non-service related 6920 -
90 Total Transportation - - -
91 - - -
NON-PAYROLL PROGRAM SUPPORT EXPENSES
TOTAL NON-PAYROLL PROGRAM SUPPORT EXPENSES
Transportation - service related (providers must maintain detailed mileage records to support expenses reported)
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 11
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
92 Rental and Property Expenses 7210-7270 -
93 Maintenance and Repairs 7310-7340 -
94 Depreciation and Amortization Expenses 7410-7460 -
95 Utilities 6410-6470 -
96 - - -
97 - - -
FACILITY, VEHICLE AND EQUIPMENT RELATED EXPENSES
TOTAL FACILITY, VEHICLE AND EQUIPMENT RELATED EXPENSES
GRAND TOTALS
Check to confirm that Col. 5 does not include room and board
Check to confirm that Col. 5 does not include room and board
Navigant -- 9/5/2017 12
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
98 Total BHD Waiver Revenues (Comprehensive, Supports and ABI)
99 Total Targeted Case Management (TCM) Revenues, if applicable
100 Total Revenues from Other Sources, if applicable
101
(If you operate multiple sites, enter total revenues earned across all your sites)
TOTAL PROVIDER REVENUES
PROVIDER REVENUES
-
Navigant -- 9/5/2017 13
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 01/00/00
PROVIDER FISCAL YEAR ENDING: 01/00/00
2 3 4 5 6
All Non-Waiver Supports,
Uniform Costs from Program Comprehensive
Chart of Provider Costs and ABI Waiver
Line Accounts General Including Program
No. Code Ledger Room and Board Costs
1
WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900
Cost Centers Additional Information
ADDITIONAL QUESTION
102 Please explain if your agency incurred partial year expenses during the provider fiscal year reported for any services, operations, or facilities.
103 Has your agency experienced significant changes in costs since the fiscal year period for which you are reporting data? If so, please explain.
Navigant -- 9/5/2017 14
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
$15.00 $17.00 $19.00 0.00% 1.00% 1.00% 5.00% 3.00% 2.00% 20 20 1 2 Home health agencies Casper Wyoming Home Health Organization
Program Employee Salaries and Wages
1 Direct Care Workers - Daytime
2 Direct Care - Swing Shift/Overnight
3 Direct Care Workers - Overnight Workers Allowed to Sleep (if different)
4 Direct Care Trainers
5 Shift and Unit Supervisors
6 Case Managers
7 Job Coaches and Vocational Trainers
8 Dieticians
9 Nurses
10 Psychiatrists
11 Psychologists
12 Physical Therapists
13 Occupational Therapists
14 Speech Therapists
15 Other Program Employees Specify:
ADDITIONAL QUESTION
1. If you assign raises, when do they take effect? Check the applicable answer.
a. End of Provider Fiscal Year
b. End of Calendar Year
c. Other (please specify) (Specify)
Notes:
(1) If your employees are paid on a salary basis, you can calculate hourly wages by dividing the annual salary by 2,080 (the number of working hours in a year based on a 40-hour work week), or for part-time salaried positions, a reasonable estimate of the
number of hours worked over the course of a year. If your employees regularly work overtime, you may divide the salary by more than 2,080 as appropriate.
(2) To convert employee raises from a dollar amount to a percentage increase in wages, divide the average hourly raise amount by the average hourly wage
(3) To calculate percent bonus, take total annual average bonus amount and divide it by the annual average salary and wages prior to payroll deductions
(4) Paid Time Off is the allowed annual hours per full-time employee including vacation, holiday, and sick time hours
(5) If a particular industry as a whole is the competitor, then note the industry. For example, if all home health agencies is your primary competitor, you can note "Any home health agency".
Line
No. Average Lowest Highest
2014
to 2015
2015
to 2016
2016
to 2017
Example
City of Primary
Competitor
State of Primary
Competitor
Type of Business
(insert description)2014 2015 2016
Hourly Wage 1
Raises: Average Annual Percent
Increase in Wages 2
Paid Time Off 4
(Complete only if
agency policy
includes a set
amount of hours
per year )
Average
Annual Paid
Training
Hours per
Employee Full-Time Part-Time
Name of Primary Competitor for
Employees 5
Bonuses: Average Annual
Percent of
Salary and Wages 3
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
Description
WORKSHEET D: PROGRAM EMPLOYEE WAGES
Note: Please provide the below information based on the "snapshot" date of August 31, 2017.
REGULAR WAGES AS OF 8/31/2017
PAID TIME OFF AND
TRAINING HOURS AS OF
8/31/2017
UNFILLED POSITIONS AS
OF 8/31/2017 LABOR COMPETITION
Navigant -- 9/5/2017 15
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
1 2 3 4 5 6 7 8
Number on
Payroll at End of
Fiscal Year
Number
Continuously
Employed
During Fiscal
Year
Number Who
Left the Agency
During the Fiscal
Year
Number on
Payroll at End of
Fiscal Year
Number
Continuously
Employed
During Fiscal
Year
Number Who
Left the Agency
During the Fiscal
Year
1
2
3
4
5 Job Coaches and Vocational Trainers
6
7
8
9
10
11
12
13
14 - - - - - - - -
WORKSHEET E: PROGRAM EMPLOYEE STAFFING AND TURNOVER
Line
No. Description
Full Time Employees Part Time Employees
NUMBER OF EMPLOYEES AND UNFILLED POSITIONS
(based on provider fiscal year listed above)
Physical Therapists
Occupational Therapists
Speech Therapists
Other Program Employees
TOTAL EMPLOYEES
Psychologists
Unfilled
Positions:
Full-Time
Unfilled
Positions:
Part-Time
Program Employees
Direct Care Workers
Direct Care Trainers
Shift and Unit Supervisors
Case Managers
Dieticians
Nurses
Psychiatrists
Navigant -- 9/5/2017 16
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
WORKSHEET E: PROGRAM EMPLOYEE STAFFING AND TURNOVER
ADDITIONAL QUESTIONS
1. What are the THREE most frequent reasons that employees cite for separation?
Mark "X" in the 3 boxes that apply.
1.1 Direct Care Employees (non-licensed):
Work location
Work schedule
Wage/Salary concerns
Sign up bonuses at new employer
Benefits package
Nature of the work
Co-worker conflicts
Relocation
Career advancement
Other (specify)
Navigant -- 9/5/2017 17
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
WORKSHEET E: PROGRAM EMPLOYEE STAFFING AND TURNOVER
1.2 Unit Supervisors, Staff Supervisors:
Work location
Work schedule
Wage/Salary concerns
Sign up bonuses at new employer
Benefits package
Nature of the work
Co-worker conflicts
Relocation
Career advancement
Other (specify)
Navigant -- 9/5/2017 18
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
WORKSHEET E: PROGRAM EMPLOYEE STAFFING AND TURNOVER
2. What are the THREE largest impacts of staff turnover on your organization?
Mark "X" in the 3 boxes that apply.
Reduced continuity of care
Reduced staff-to-client ratios
Increased safety risks
Difficulty meeting safety or health standards
Reduction in services (either amount or type) because of increased costs or lack of staff
Increased training costs
Increased hiring or recruitment costs
Inability to fulfill paperwork requirements
Burnout of existing staff
Inability to terminate undesirable or marginal staff
Lower qualification of new employees
Administrative staff working direct care
Reduced training for new employees
Other (specify)
Navigant -- 9/5/2017 19
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
Please provide information from the current provider fiscal year.
Table 1: Questions for Organizations Currently Offering Health Insurance Coverage
2 3
Example Response
Example
1 Yes
2Health plan/insurance
broker
3 N/A
4 $500,000
5 Yes
6 $100.00
7 $400.00
On average, how much does a typical employee with single coverage contribute toward his/her own monthly premium?
WORKSHEET F: EMPLOYEE HEALTH INSURANCE BENEFITS
Complete only Table 1 if your organization currently offers health insurance . Complete only Table 2 if your organization does not currently offer health insurance.
Line
No.
1
Question
Employer contribution toward health insurance premiums
Does your organization currently offer health care coverage?
Does your organization purchase health insurance from a health plan or insurance broker (i.e., your organization does not
assume any risk beyond the premium), or self-insure?
If your organization self-insures, does your organization purchase stop-loss coverage?
If your organization self-insures, did you have any costs for lasering (e.g., costs related to a higher reinsurance deductible for a
particular individual) for the provider fiscal year reported on Worksheet C? If so, please report the lasering on this line less
what the normal stop loss threshold payment amount would be.
Does your organization contribute toward health insurance premiums?
On average, how much does your organization (the employer) contribute toward the monthly plan premium of one typical
employee with single coverage? If your organization self-insures 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).
Navigant -- 9/5/2017 20
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
Please provide information from the current provider fiscal year.
WORKSHEET F: EMPLOYEE HEALTH INSURANCE BENEFITS
Complete only Table 1 if your organization currently offers health insurance . Complete only Table 2 if your organization does not currently offer health insurance.
8 $500.00
9 $1,500
10 $3,000
11 Yes
12 12 months
13 30.00
14 17
15 10
16 15
17 8
18 6
19 1
20 1How many waiver program direct service staff receiving health insurance from your organization selected a family coverage
plan?
How many direct service employees work more than the minimum number of hours per week to be eligible for health
insurance?
How many waiver program direct service employees work less than the minimum number of hours per week to be eligible
for health insurance?
Of the waiver program direct service staff employed by your organization, how many are currently eligible for health
insurance (regardless of whether the eligible staff have signed up for coverage)?
How many waiver program direct service staff currently receive health insurance from your organization?
How many waiver program direct service staff receiving health insurance from your organization selected an employee-plus-
one coverage plan?
What is the average annual deductible for the health insurance offered for individual coverage?
What is the average annual deductible for the health insurance offered for family coverage?
Are direct service staff eligible to receive health insurance through your organization?
If yes, what is the waiting period before direct service staff are eligible for health insurance (in months)?
What is the minimum number of hours per week that a direct service employee must work to be eligible for health insurance?
How many waiver program direct service staff receiving health insurance from your organization selected a single coverage
plan?
On average, how much is the total monthly premium for a typical employee with single coverage (this number should equal the
sum of lines 5 and 6)?
Navigant -- 9/5/2017 21
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
Please provide information from the current provider fiscal year.
WORKSHEET F: EMPLOYEE HEALTH INSURANCE BENEFITS
Complete only Table 1 if your organization currently offers health insurance . Complete only Table 2 if your organization does not currently offer health insurance.
Table 2: Questions for Organizations that Do Not Currently Offer Coverage
2 3
Example
1 Yes
2016
June
3
a. Employer portion of the premium was too high 1
b. Employee portion of premium was too high; direct care staff could not afford it
c. 2
d.
e.
f. Concerns regarding the economy 3
g. Other Specify Insert comments
2If yes, when did your organization stop offering health care insurance to waiver program direct service staff (insert month
and year)
If yes, why did your organization stop offering health care insurance (rank the top three reasons)?
Concerns related to benefit requirements under the Affordable Care Act
Direct care staff have other offers of insurance (via family member, public program or
individual insurance market)
Anticipated/unpredictable increases in health insurance premiums
Employer contribution toward health insurance premiums
If your organization does not currently offer coverage, has your organization offered health insurance to waiver program
direct service staff in the past?
Line
No.
1
Category ResponseExample
Navigant -- 9/5/2017 22
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
Please provide information from the current provider fiscal year.
WORKSHEET F: EMPLOYEE HEALTH INSURANCE BENEFITS
Complete only Table 1 if your organization currently offers health insurance . Complete only Table 2 if your organization does not currently offer health insurance.
4
a. Employer portion of the premium is too high 1
b.
c. 2
d.
e.
f. Concerns regarding the economy 3
g. Other Specify Insert comments
5 Yes
Concerns related to benefit requirements under the Affordable Care Act
If no, what are the reasons for not offering health care insurance (rank the top three reasons)?
Direct care staff have other offers of insurance (via family member, public program or
individual insurance market)
Employee portion of premium is too high; direct care staff can not afford it
Anticipated/unpredictable increases in health insurance premiums
If no, are you considering offering coverage to comply with Affordable Care Act legal requirements?
Navigant -- 9/5/2017 23
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
CARF CERTIFICATION STATUS: 1/0/1900
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
Please provide information from the current provider fiscal year.
Table 1: Questions for Organizations Currently Offering Retirement Benefits
2 3
Example Response
1 Yes
2 12 Months
330 hours/week OR
120/month
4 15
5 8
6 4.00%
Table 2: Questions for Organizations that Do Not Currently Offer Retirement Benefits
2 3
Example Response
Example
1 Yes
2016
June
What is the minimum number of hours per week/month that an employee must work to be eligible for retirement benefits?
Of the waiver program direct service staff employed by your organization, how many are currently eligible for retirement
benefits?
How many waiver program direct service staff received retirement contributions from your organization for the provider
fiscal year reported in Worksheet C?
What was your organization's average annual retirement contribution for waiver program direct service staff that are
participating in the retirement benefit as a percent of waiver program direct service staff salary and wages for the provider
fiscal year reported in Worksheet C?
WORKSHEET G: EMPLOYEE RETIREMENT BENEFITS
Line
No.
1
Question
Complete only Table 1 if your organization currently offers retirement benefit. Complete only Table 2 if your organization does not currently offer retirement benefit.
Employer contribution toward health insurance premiums
If your organization does not currently offer retirement benefits, has your organization offered retirement benefits to waiver
program direct service staff in the past?
2 If yes, when did your organization stop offering retirement benefits to direct service staff (insert month and year)
1
Does your organization contribute to a 401k, 403b or other retirement plan for your direct service staff?
Line
No. Category
If yes, what is the waiting period before staff are eligible for retirement contributions (in months)?
Navigant -- 9/5/2017 24
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
CARF CERTIFICATION STATUS: 1/0/1900
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
Please provide information from the current provider fiscal year.
WORKSHEET G: EMPLOYEE RETIREMENT BENEFITS
Complete only Table 1 if your organization currently offers retirement benefit. Complete only Table 2 if your organization does not currently offer retirement benefit.
3
a. Decrease in State funding of waiver programs 1
b. Concerns regarding the economy 3
c. 2
d.
e. Other Specify Insert comments
4
a. Decrease in State funding of waiver programs 1
b. Concerns regarding the economy
c. 2
d.
g. Other Specify Insert comments
Need to maintain health insurance benefits over other benefits
Employees are not interested
Need to maintain health insurance benefits over other benefits
Employees are not interested
If no, what are the reasons for not offering retirement benefits (rank the top three reasons)?
If yes, why did your organization stop offering retirement benefits (rank the top three reasons)?
Navigant -- 9/5/2017 25
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
PROVIDER NAME: Provider Name
2 3
Comprehensive
Targeted Supports
Line Case and ABI
No. Management Waiver Programs
1 How many participants does your organization currently serve?
2 0-3 hours per month
3 4-6 hours per month
4 7-9 hours per month
5 10+ hours per month
6
REASONS FOR VARIATION AMONG PARTICIPANTS
Other (Please describe):
What are the most common reasons for exceeding six hours of case management per month for a given
participant? Please select all that apply.
Looking at your total caseload, approximately how many participants require, on average, the
following amounts of case management per month:
WORKSHEET H: CASE MANAGEMENT QUESTIONS
1
Supplemental Information
PARTICIPANTS
Note: Complete this worksheet only if your organization provides waiver case management services, otherwise leave blank. Please provide information from the current provider
fiscal year.
Crisis Management
Communicating with Family and Guardians
Difficult Participant Behavior
Recurrent Medical Issues
Finding or Changing Providers
Documentation
Navigant -- 9/5/2017 26
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
PROVIDER NAME: Provider Name
WORKSHEET H: CASE MANAGEMENT QUESTIONS
Note: Complete this worksheet only if your organization provides waiver case management services, otherwise leave blank. Please provide information from the current provider
fiscal year.
7 Monthly rate unit
8 15 minute rate unit
For how many participants do you currently bill for using a monthly and a 15-minute unit?
UNITS
Navigant -- 9/5/2017 27
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
1 3 4 5
Worksheet Yes No Not Applicable
If you are completing this survey for a particular provider site, have you specified the site on Line 29?
B: Services Have you identified all the waiver services your organization (or relevant site) delivers to clients?
Have you included all of the costs from your general ledger in the appropriate cost center and line number?
Have you reported all of your non-waiver program costs in the appropriate cost center and line number in Column 4?
Have you accounted for room and board costs in Column 4, "Non-Waiver Program Costs"?
Did you check the boxes in Column 6 to indicate that your responses in column 5 do not include room and board costs?
Did you report average hourly wages, as of August 31, 2017, for each employee type in Column 1?
Did you report the lowest hourly wage paid to each employee type in Column 2 and the highest hourly wage in Column 3, as of August 31, 2017?
Did you report the average amount of paid time off allowed to each employee type in Column 10, including vacation, holiday, and sick time?
Did you report the average amount of paid training hours provided annually for each employee type in Column 11?
Did you provide the relevant information in Columns 12-13 regarding unfilled full-time and part-time positions?
Did you provide the relevant information in Columns 14-17 about your primary competitor for employees?
Did you complete "Additional Question" 1, if applicable?
WORKSHEET I: ERROR SELF-CHECK
2
A: Provider
Info
Did you enter the total number of full-time and part-time employees employed by your organization (not site-specific) at the end of your most recent fiscal year?
C: Costs
D: Wages
Did you report any raises you gave employees between 2015 and 2017 in the appropriate column (4-6) as a percentage increase from the previous year?
Did you input information for up to 4 provider sites operated by your organization, if applicable?
Did you input the number of waiver participants served at each provider site during the provider fiscal year entered in Worksheet A?
If you have reported costs in the "Other" expenses row within any of the cost centers, have you entered a description of the expense(s) in the box provided?
Did you report any bonuses you gave employees in 2014 to 2016 in the appropriate column (7-9) as a percentage from that year?
Navigant -- 9/5/2017 28
Provider Cost and Wage Survey ("Full Survey")
Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs
Wyoming Department of Health, Behavioral Health Division
PROVIDER NAME: Provider Name
PROVIDER SITE: Please specify: all sites or a specific site
PROVIDER FISCAL YEAR BEGINNING: 1/0/1900
PROVIDER FISCAL YEAR ENDING: 1/0/1900
1 3 4 5
WORKSHEET I: ERROR SELF-CHECK
2
E: Turnover
Did you report the number of unfilled full-time and part-time employees, by type, as of the end of your most recent fiscal year?
Did you complete "Additional Questions" 1 and 2?
Did you answer the questions in Table 1 if your agency currently offers health insurance benefits?
Did you answer the questions in Table 2 if your agency does not currently offer health insurance benefits?
G: Retirement Did you answer the questions on this worksheet, regardless of whether you offer retirement benefits?
H: CM
Questions
If your agency provides case management services, did you answer each question separately for individuals receiving TCM and waiver case management
services?
Did you report the number of full-time and part-time employees who were continuously employed during your most recent fiscal year in Columns 2 and 5,
respectively, for each employee type that you employ?
Did you report the number of full-time and part-time employees who left the agency during your most recent fiscal year in Columns 3 and 6, respectively, for
each employee type that you employ?
Did you report the number of full-time and part-time employees who were on the payroll as of the last day of your most recent fiscal year in Columns 1 and 4,
respectively, for each employee type that you employ?
F: Health
Insurance
Navigant -- 9/5/2017 29