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    Wyoming Medicaid Annual Report state fiscal year 2017 Matthew H. Mead, Governor Thomas O. Forslund, Director Teri Green, State Medicaid Agent


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    Contents SFY 2017 Snapshot ..............................................................................................................................................1 Wyoming Medicaid Background ........................................................................................................................ 3 Highlights and Initiatives ................................................................................................................................... 7 SFY 2017 Performance ....................................................................................................................................... 9 Eligibility Categories ..........................................................................................................................................13 Services ..............................................................................................................................................................19 Ambulance ............................................................................................................................................ 25 Ambulatory Surgery Centers ............................................................................................................... 26 Behavioral Health ................................................................................................................................. 26 Care Management Entity ..................................................................................................................... 28 Clinic/Center ......................................................................................................................................... 28 Dental .................................................................................................................................................... 29 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies ................................................... 30 End Stage Renal Disease ......................................................................................................................31 Federally Qualified Health Center ....................................................................................................... 32 Home Health ......................................................................................................................................... 33 Hospice.................................................................................................................................................. 34 Hospital ................................................................................................................................................. 35 Inpatient Services .................................................................................................................... 36 Outpatient Services ................................................................................................................. 37 Emergency Room Utilization .................................................................................................. 38 Intermediate Care Facility - Intellectually Disabled ............................................................................41 Laboratory .............................................................................................................................................41 Nursing Facility .................................................................................................................................... 42 Program of All-Inclusive Care for the Elderly (PACE)........................................................................ 43 Physicians and Other Practitioners ..................................................................................................... 43 Prescription Drugs ............................................................................................................................... 45 Psychiatric Residential Treatment Facility ......................................................................................... 46 Public Health or Welfare ...................................................................................................................... 47 Public Health Federal ........................................................................................................................... 47 Rural Health Clinic ............................................................................................................................... 48 Vision .................................................................................................................................................... 48 Waivers ................................................................................................................................................. 49 Subprograms and Special Populations ............................................................................................................ 57 Subprograms ............................................................................................................................................... 57 Drug Utilization Review ....................................................................................................................... 57 Health Information Technology........................................................................................................... 58 Project Out ............................................................................................................................................ 59 Administrative Transportation ............................................................................................................ 59 Patient Centered Medical Home .......................................................................................................... 59 Health Check......................................................................................................................................... 59 Special Populations ....................................................................................................................................60 Medicaid/Medicare Dual Enrolled .......................................................................................................60 Foster Care ............................................................................................................................................ 64 Appendix A: Supplemental Tables.................................................................................................................... 67 Appendix B: Reimbursement Methodology ......................................................................................................81 Appendix C: Eligibility Requirements and Benefits ........................................................................................ 89 Appendix D: Glossary and Acronyms .............................................................................................................. 93 Appendix E: Data Methodology ........................................................................................................................ 99 •i


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    LIST OF FIGURES Figure 1. Wyoming Department of Health Organization Chart ........................................................................ 3 Figure 2. Enrollment History: Unique and Monthly Average ........................................................................... 9 Figure 3. Monthly Medicaid Enrollment by State Fiscal Year........................................................................... 9 Figure 4. Wyoming County Map by Medicaid Enrollment .............................................................................. 10 Figure 5. Expenditure History ........................................................................................................................... 11 Figure 6. Change in Expenditures from SFY 2016 to SFY 2017 for Top Services .......................................... 11 Figure 7. Recipient History ................................................................................................................................12 Figure 8. Recipient Utilization versus Expenditure Breakdown by Service Type ..........................................12 Figure 9. Eligibility Category Descriptions.......................................................................................................13 Figure 10. Enrolled Members versus Expenditures by Eligibility Category ....................................................14 Figure 11. Enrollment History by Eligibility Category .....................................................................................15 Figure 12. Change in Expenditures from SFY 2016 to SFY 2017 by Eligibility Category ..............................16 Figure 13. Change in Expenditures and Recipients from SFY 2016 to SFY 2017 by Eligibility Category.....17 Figure 15. Percent of Total Expenditures by Service........................................................................................21 Figure 14. Percent of Total Unduplicated Recipients by Service .....................................................................21 Figure 16. Change in Expenditures for Top Services .......................................................................................21 Figure 17. Behavioral Health Expenditures and Recipient History for ID/DD/ABI ....................................... 27 Figure 18. Top Five Behavioral Health Diagnosis Codes by Expenditures for all Provider Types................ 27 Figure 19. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies History by Expenditures ..... 30 Figure 20. Top 5 Home Health Providers by Expenditures in SFY 2017 ....................................................... 33 Figure 21. Hospital Inpatient-Outpatient Breakdown History by Expenditures ........................................... 35 Figure 22. Percent of Hospital Inpatient Expenditures by Level of Care ....................................................... 36 Figure 23. Change in Hospital Inpatient Expenditures by Level of Care ....................................................... 36 Figure 24. Emergency Room Expenditures by Eligibility Category ............................................................... 38 Figure 25. Average Yearly Growth Rate of Emergency Room Expenditures by Eligibility Category ........... 38 Figure 26. Change in Emergency Room Utilization from SFY 2016 to SFY 2017 by Eligibility Category .. 39 Figure 27. Emergency Room Utilization vs Total Medicaid by Eligibility Category ...................................... 40 Figure 28. Nursing Facility Payment Descriptions ......................................................................................... 42 Figure 29. Physician and Other Practitioner Expenditure Breakdown by Eligibility Category .................... 44 Figure 30. Expenditures for Court Ordered Psychiatric Residential Treatment Facility Services with Incorrect Language or No Medical Necessity .................................................................................................. 46 Figure 31. Medicaid Waivers............................................................................................................................. 49 Figure 32. Waiver vs Non-Waiver Expenditures History ................................................................................ 50 Figure 33. Total Expenditure History for Transition from Adult and Child ID/DD Waivers to Comprehensive and Supports Waivers ........................................................................................................................................51 Figure 34. Non-Waiver Services Expenditure History for Transition from Adult and Child ID/DD Waivers to Comprehensive and Supports Waivers .............................................................................................................51 Figure 36. SFY 2017 Total Waiver Expenditure Breakdown by Waiver ......................................................... 52 Figure 35. SFY 2017 Waiver-Only versus Non-Waiver Services by Waiver................................................... 52 Figure 37. Wyoming Health Information Exchange and Medicaid ................................................................ 58 Figure 38. Dual Enrolled Claims Coverage Process ........................................................................................60 Figure 39. Dual Enrolled as Percent of Total Medicaid in SFY 2017 ...............................................................61 Figure 41. History of Crossover Expenditures as Percent of Total Dual Expenditures ..................................61 Figure 40. History of Dual Enrollment and Expenditures as Percent of Total Medicaid ...............................61 Figure 42. Crossover Expenditures as Percent of Dual Expenditures by Service Area ..................................61 Figure 44. Percent of Total Unduplicated Dual Recipients by Service........................................................... 63 Figure 43. Dual Expenditures as Percent of Total Medicaid Expenditures by Service.................................. 63 Figure 45. Medicaid Foster Care as Percent of Total Medicaid Expenditures and Enrollment..................... 64 Figure 46. Medicaid Foster Care Recipient and Expenditures History .......................................................... 64 Figure 47. Percent of Foster Care Expenditures by Service - Medicaid versus State-Only........................... 65 Figure 48. Medicaid Foster Care as Percent of Total Medicaid Expenditures for Top Foster Care Services 65 ii •


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    LIST OF TABLES Table 1. Division of Health Care Financing Budget ........................................................................................... 4 Table 2. Wyoming Medicaid Advisory Groups and Committees ...................................................................... 5 Table 3. Medicaid Cost Avoidance and Recoveries - SFY 2017 ........................................................................ 5 Table 4. Employment and Mean Wages by Occupation .................................................................................... 6 Table 5. Change in Medicaid Enrollment ........................................................................................................... 9 Table 6. Medicaid Enrollment by County ......................................................................................................... 10 Table 7. Expenditure History by Service Type ................................................................................................. 11 Table 8. Recipient History by Service Type .....................................................................................................12 Table 9. Eligibility Category Summary .............................................................................................................14 Table 10. Enrollment History by Eligibility Category.......................................................................................15 Table 11. Expenditures History by Eligibility Category ....................................................................................16 Table 12. Unique Recipient History by Eligibility Category.............................................................................17 Table 13. Covered Services ................................................................................................................................19 Table 14. Service Utilization Summary ........................................................................................................... 20 Table 15. Expenditure History by Service ........................................................................................................ 22 Table 16. Expenditure History by Other Service ............................................................................................. 23 Table 17. Recipient Count History by Service .................................................................................................. 24 Table 18. Ambulance Services Summary ........................................................................................................ 25 Table 19. Ambulatory Surgery Center Services Summary ............................................................................. 26 Table 20. Behavioral Health Services Summary............................................................................................. 27 Table 21. Top Five Behavioral Health Diagnosis Codes by Expenditures for all Provider Types.................. 27 Table 22. Care Management Entity Services Summary ................................................................................. 28 Table 23. Clinic/Center Services Summary ..................................................................................................... 28 Table 24. Dental Services Summary ................................................................................................................ 29 Table 25. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Services Summary ............... 30 Table 26. End Stage Renal Disease Services Summary ..................................................................................31 Table 27. Federally Qualified Health Center Services Summary .................................................................... 32 Table 28. Home Health Services Summary..................................................................................................... 33 Table 29. Top 5 Home Health Providers by Expenditures in SFY 2017 ......................................................... 33 Table 30. Hospice Services Summary ............................................................................................................. 34 Table 31. Total Hospital Services Summary .................................................................................................... 35 Table 32. Inpatient Hospital Services Summary............................................................................................. 36 Table 33. Outpatient Hospital Services Summary .......................................................................................... 37 Table 34. Emergency Room Utilization Summary.......................................................................................... 38 Table 35. Emergency Room Utilization by Eligibility Category ..................................................................... 39 Table 36. Emergency Room Utilization vs Total Medicaid by Eligibility Category ....................................... 40 Table 37. Intermediate Care Facility - Intellectually Disabled Services Summary ........................................41 Table 38. Laboratory Services Summary .........................................................................................................41 Table 39. Nursing Facility Services Summary ................................................................................................ 42 Table 40. Program of All-Inclusive Care for the Elderly Services Summary................................................. 43 Table 41. Physician and Other Practitioner Services Summary..................................................................... 44 Table 42. Prescription Drug Services Summary ............................................................................................. 45 Table 43. Pharmacy Cost Avoidance - SFY 2017............................................................................................. 45 Table 44. Prescription Drug Rebates History .................................................................................................. 45 Table 45. Psychiatric Residential Treatment Facility Services Summary ..................................................... 46 Table 46. Public Health or Welfare Services Summary .................................................................................. 47 Table 47. Public Health, Federal Services Summary ...................................................................................... 47 Table 48. Rural Health Clinic Services Summary ........................................................................................... 48 Table 49. Vision Services Summary ................................................................................................................ 49 Table 50. Home and Community Based Services Waiver Summary ............................................................. 50 Table 51. Home and Community Based Services Waiver Expenditures History by Waiver ..........................51 Table 52. Acquired Brain Injury Waiver Summary ......................................................................................... 52 Table 53. Community Choices Waiver Summary ............................................................................................ 53 Table 54. Comprehensive Waiver Summary.................................................................................................... 54 • iii


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    Table 55. Supports Waiver Summary .............................................................................................................. 55 Table 56. Pregnant by Choice Waiver Summary ............................................................................................. 55 Table 57. Medicaid/Medicare Dual Enrollment Summary ...............................................................................61 Table 58. Dual Enrolled Member Service Utilization Summary .................................................................... 62 Table 59. Foster Care Summary ....................................................................................................................... 64 Table 60. Foster Care Summary by Services - Medicaid versus State-Only ................................................. 65 Table 61. Behavioral Health Services by Provider Type ................................................................................. 67 Table 63. Inpatient Hospital Levels of Care Summary - SFY 2017 ................................................................ 68 Table 62. Waiver Services by Waiver ............................................................................................................... 68 Table 65. Inpatient Hospital Recipient History by Levels of Care .................................................................. 69 Table 64. Inpatient Hospital Expenditures History by Levels of Care ........................................................... 69 Table 66. Wyoming Medicaid Births ................................................................................................................ 70 Table 67. County Summary .............................................................................................................................. 70 Table 68. Provider Summary by Taxonomy - SFY 2017 ..................................................................................71 Table 69. Top 20 Provider Taxonomies by Expenditures................................................................................ 73 Table 70. Provider Count History by Taxonomy ............................................................................................. 74 Table 71. Provider Expenditures History by Taxonomy .................................................................................. 77 Table 72. Reimbursement Methodology and History by Service Area............................................................81 Table 73. Income Limits by Eligibility Category.............................................................................................. 89 Table 74. Monthly Income Standard Values by Family Size ........................................................................... 89 Table 75. Eligibility Requirements ...................................................................................................................90 Table 76. Acronyms........................................................................................................................................... 98 Table 77. Medicaid Chart A Eligibility Program Codes ................................................................................. 100 Table 78. Medicaid Chart B Eligibility Program Codes ................................................................................. 104 Table 79. Data Parameters by Service Area .................................................................................................. 105 Table 80. Data Parameters for Subprogram and Special Populations ..........................................................110 Table 81. Emergency Department Procedure Code Value Set ........................................................................111 iv •


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    SFY 2017 Snapshot state fiscal year 2017At a Glance Enrollment 89,328 89,684 88,642 91,062 88,775 84,785 84,785 members enrolled at any point 69,610 69,479 70,389 74,628 66,696 63,247 during the SFY with 63,247 SFY SFY SFY SFY SFY SFY 2012 2013 2014 2015 2016 2017 members enrolled on average each month Sheridan 43% Park Crook Campbell Big Horn Johnson Teton Washakie of enrolled members Hot Springs Weston average length 60% reside in 3 counties: Niobrara of enrollment is Laramie (17%) Fremont Natrona Converse Natrona (15%) 9.2 Sublette of enrolled Fremont (11%) Goshen Platte members are 9,700-14,216 1,435-1,968 Lincoln Carbon months children 3,671-6,300 919-1,177 Uinta Sweetwater Laramie 2,115-3,626 335-898 Albany Expenditures $517,257,164 $527,531,608 $555,419,725 $555 million total paid to providers for the $500,931,031 $517,622,524 $554,583,138 below services SFY SFY SFY SFY SFY SFY 2012 2013 2014 2015 2016 2017 Remaining 4% Medical Long-Term Care Dental, $296,606,571 $239,788,830 Vision, & Other 53% 43% services Recipients 58% of recipients 3,492 75,921 enrolled members 32% were female providers paid with over 18,000 providers actively enrolled at any point during the SFY with claims paid Female 8% 84% had physician & other practitioner claims 32% 22% Male 2% $687 preliminary 56% had prescription drug claims 5% Per Member Per Month 52% had hospital claims 0-20 Years 21-64 Years 65+ SFY 2017 At a Glance • 1


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    Wyoming Medicaid Background Wyoming Medicaid Background WHAT IS WYOMING MEDICAID? Wyoming Medicaid is a joint federal and state government program that pays for medical care for low income and medically needy individuals and families. There are currently four major categories of eligibility: Children, Pregnant Women, Adults, and Aged, Blind, or Disabled (ABD). Wyoming has not extended optional eligibility to adults under 133% of the Federal Poverty Level (FPL). Medicaid eligibility is based on residency, citizenship and identity, social security eligibility as verified by social security number, family income and, to a lesser extent, resources and/or health care needs. The Division of Healthcare Financing (DHCF) within the Wyoming Department of Health (WDH) is the state-appointed entity for administration of Wyoming Medicaid. DHCF partners with the Fiscal Division for accounting and budgeting services and with the Behavioral Health Division for the administration of waivers that serve persons with developmental disabilities or acquired brain injuries. Wyoming Department of Health Thomas O. Forslund Director Aging Public Director's Behavioral Division of Health Fiscal Division Health Office Health Division Care Financing Division Chris Newman Teri Green Administrator Administrator and Medicaid State Medicaid Agent Fiscal Developmental Medicaid Disabilities (including Medicaid Medicaid Waivers) Long-Term Care Waivers Non-Medicaid Provider Services Medication Donation Program Integrity Eligibility Kid Care CHIP Analytics, Information, MMIS, Special Projects Medicaid Medical Officer Figure 1. Wyoming Department of Health Organization Chart Wyoming Medicaid Background • 3


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    Enrolled providers must submit claims to Medicaid for reimbursement within one year of the date of service. These claims are processed through the Medicaid Management Information System (MMIS). This Annual Report focuses on the members enrolled during SFY 2017 and claims paid during SFY 2017, regardless of when service was rendered. Table 1 below addresses the other DHCF expenditures in SFY 2017, such as administrative costs, capital investment, the Kid Care CHIP program, and non-Medicaid programs. Table 1. Division of Health Care Financing Budget Medicaid Related Expenditures Expenditure Type SFY 2017(millions) Annual Report Benefit Expenditures (this report)1 $555.4 Medicaid Administration $36.9 Nursing Facilities Tax Assessment $30.0 Hospital Qualified Rate Adjustment (QRA) Payments $30.6 Medicare Buy-In $17.7 Medicaid One-Time Capital Expenses for New Technology Systems (WES, MMIS, Other) $14.3 Medicare Clawback (Part D) $15.9 Physician Electronic Health Record (EHR) Incentives $1.2 Other2 -$4.9 Subtotal Medicaid Expenditures $697.1 Drug Rebates -$32.5 Total Medicaid Expenditures $664.6 Non-Medicaid Expenditures Children’s Health Insurance Program (CHIP) $9.9 CHIP Administration $0.6 State Only Foster Care and General Fund Foster Care (Court Orders) $1.8 Total Health Record (Health Information Exchange (HIE)) $2.4 State Only Other $1.9 Total Non-Medicaid Expenditures $16.6 Total Division of Healthcare Financing $681.2 WYOMING MEDICAID FUNDING Wyoming Medicaid Benefits and general administrative expenditures Federal (50% Federal) 52% State Medical Personnel and Technology- 43.4% related operating expenditures SFY 2017 (75% Federal) HEALTH CARE Capital investment expenditures FINANCING (90% Federal) FUNDING Hospital QRA payments and SOURCES Nursing Facility tax (50% Federal, 50% Provider) State-only funded programs (100% State) Other Federal sources State General Fund Other 4.6% 1 Includes reductions in expenditures due to recoveries processed through the MMIS. 2 Adjustment to reflect timing difference related to drug rebate and claims differences between WOLFs and MMIS claims data. 4 • Wyoming Medicaid Background


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    Advisory groups and committees offer independent guidance and provider industry expertise to the Medicaid program. Table 2. Wyoming Medicaid Advisory Groups and Committees Advisory Group Members Description Dental Advisory Group (DAG) Two specialists, three general dentists, and Represents a wide range of interests, experience, representatives from Medicaid and its fiscal dental specialties and various areas of the state, agent, Conduent. while advising Medicaid regarding administration of the dental program. Long-Term Care Advisory Group Nursing Home Association leadership, five Focuses on issues and recommendations with nursing home providers, a home health institutional and community-based long-term care provider, a hospice provider, an assisted providers. living provider, a Long-Term Care waiver case manager, and an Independent Living Center representative Medical Advisory Group (MAG) Wyoming Hospital Association, Wyoming Focuses on new and upcoming issues within Medical Society, executives from hospitals the healthcare industry, member concerns, and throughout Wyoming, physicians, and relevant presentations. Works to develop solutions medical practitioners to issues. Pharmacy & Therapeutics Committee Six physicians, five pharmacists, one allied Provides recommendations regarding prospective (P&T) health professional. drug utilization review, retrospective drug utilization review and education activities to Medicaid. Tribal Leadership Advisory Group Tribal Business Council members, Focuses on new and upcoming issues within leadership and executives from tribal health the healthcare industry, consultation with the clinics and Indian Health Services, long-term Tribal leaders, updates from facilities, and work care providers, and representatives from all to develop solutions and programs to decrease Wyoming Department of Health divisions barriers for this group. Wyoming Medicaid's Program Integrity unit is tasked with reviewing, auditing, and investigating providers for claims lacking sufficient documentation or incorrect billing. This team manages the associated administrative process, collects recoveries of State funds, as applicable, and ensures the State's compliance to the Federal standards regarding the reduction of Fraud, Waste, and Abuse. The Program Integrity unit oversees recovering funds from third party liability (TPL) and seeking other recoveries, such as Estate, drug (J-code), and credit balances. Table 3. Medicaid Cost Avoidance and Recoveries - SFY 2017 Program Area Description Amount Recovered Program Integrity Process of reviewing, auditing, and investigating providers for claims $241,706 lacking sufficient documentation or incorrect billing. Funds recovered from other responsible parties which may include Third Party Liability Medicare, health insurance companies, worker's compensation, casualty $1,682,650 Recoveries insurance companies, or a spouse/parent court order to carry health insurance. An estimate of costs not incurred by the State when claims are denied up front due to third party liability. This figure is calculated based on billed charges, not on the final amount Medicaid would have paid -- as Third Party Liability the claims are not fully processed once TPL is determined; therefore, $12,119,075 Cost Avoidance this figure is only an estimate and may be inflated. As such, the program integrity team is currently reviewing and auditing their process for calculating this figure. Funds recovered from any real or personal property a client had legal title or interest in at the time of death, including such assets conveyed Estate Recoveries to a survivor heir, or assign of the deceased individual through joint $3,264,146 tenancy, tenancy in common, survivorship life estate, living trust or other arrangement. Moneys recovered from providers whose credits (i.e. take-backs or Credit Balances $37,012 adjustments) exceed their debits (pay-outs or paid claims). Total Recovered Dollars (excluding Cost Avoidance) $5,225,514 Total Recovered Dollars (including Cost Avoidance) $17,344,589 Wyoming Medicaid Background • 5


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    WYOMING DEMOGRAPHICS & ECONOMY In SFY 2017... 600,000 14.4% of Wyoming residents 500,000 400,000 576,893 583,223 584,153 586,107 585,501 586,900 were enrolled in Medicaid 300,000 27% of the state population is under age 20 200,000 Female 100,000 Male 89,328 89,684 88,642 91,062 88,775 84,785 - 30% SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 State Population Estimates Medicaid Enrollment 14% State Population3 increased Medicaid enrollment decreased 28% by by 13% 7% 8% 1.7% from 2012 to 2017 5.1% from SFY 2012 to SFY 2017 Age 0-19 Age 20-64 Age 65+ How Wyoming Compares National Wyoming 12.7% 10.9% $59,039 $57,829 4.4% 4.1% Unemployment Rate4 Poverty Rate5 Median Income6 Table 4. Employment and Mean Wages by Occupation7,8 Employment Total Wages Total Percent Mean Hourly Wages Percent Change Change 2006 to 2016 2006 to 2016 2016 US WY US WY US WY All Occupations 5.9% 5.3% 26.6% 36.7% $23.86 $22.52 Healthcare Practitioners & Technical Occupations 23.9% 31.7% 2.2% 36.3% $30.49 $37.30 Healthcare Support Workers 16.1% 4.4% 13.4% 35.6% $13.42 $15.00 3 2017 forecast population prepared by Wyoming Department of Administration & Information, Economic Analysis Division (http://eadiv.state.wy.us), August 2017 4 Senate Joint Economic Committee, State Economic Snapshots, August, 2017, https://www.jec.senate.gov/public/_cache/files/e34e5d8e-cdd4-4088-908d- 73b553db8af6/state-economic-snapshots-august-2017.pdf 5 Historical Poverty Tables-People and Families, Tables 9, 21: http://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty- people.html 8 US Census Bureau, Historical Income Table H-8. https://www2.census.gov/programs-surveys/cps/tables/time-series/historical-income-households/h08. xls 6 Bureau of Labor Statistics, May 2016 State Occupational Employment and Wage Estimates, Wyoming. http://www.bls.gov/oes/current/oes_wy.htm 7 Bureau of Labor Statistics, May 2016 State Occupational Employment and Wage Estimates, United States. http://www.bls.gov/oes/current/oes_nat.htm 6 • Wyoming Medicaid Background


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    Highlights and Initiatives Highlights & Initiatives During SFY 2017, Medicaid implemented a number of changes to meet federal or state government mandates, to meet the specific medical needs of Medicaid individuals, and to improve access to care and care options. 2016 Access Review Monitoring Plan containing analysis LEGISLATION of provider network & • 2016 HEA0024 ease of access Created a tax assessment program to draw down additional federal funding submitted to CMS on July 1, 2016 for qualifying hospitals • 2016 HEA0046 Created an intergovernmental Completed procurement Completed transfer program for enrolled non- for the Wyoming ICD-10 enrollment of all state government owned nursing Frontier Information (WYFI) statewide implemented for ordering, referring, facilities in order to draw down Health Information all providers prescribing, and additional federal funding for Exchange (HIE), with qualifying Wyoming nursing facilities 90% FFP funding for October 1, 2016 attending providers Design, Development, as required. Implementation (DDI) activities. Starting November 2016 Deloitte is now vendor for Qualified Hospitals allowed to submit Medicaid applications for individuals TRIBAL HEALTH State Plan Amendment approved to: operations and maintenance of Wyoming Eligibility System (WES) 2/3 of State seeking presumptive • Remove limitations on daily encounters eligibility for Breast/ Mitigating long-standing Supplemental Cervical Cancer, Child to Tribal Health providers defects, developing/ MAGI, Family Care MAGI, • Increase reimbursement above the OMB implementing enhancements Payments and Former Foster Youth rate for select services while optimizing now made by eligibility programs. infrastructure & fucnction • Allow Tribal End Stage Renal Disease direct deposit Clinic to bill an encounter rate • Allow Tribal Health providers to BUDGET receive an encounter payment for each $54,438,246 $28,104,512 prescription dispensed required reduction in corresponding reduction State General Funds in Federal Funds Early estimates project an expenditure for 2017-18 biennium increase of $7-10 million per year in Total budget (State, In total, State General Federal, Other funds) federal dollars to Wyoming Tribal Health Fund Reduced by reduced by providers. 9.01% 5.6% Reductions primarily concentrated on Medicaid; however, reductions were also made to Kid Care CHIP program state Supported general fund budget and other non-Medicaid programs. Some PROGRAM INTEGRITY implementation major reductions included: • Eliminated State Licensed Shelter Care Program allowing for • Implemented prior authorization of claims 50/50 FMAP for a program previously covered by 100% state requirement for home health, behavioral processing for general fund health, and occupational/physical/speech • Reduced provider reimbursement rates by 3.3% therapy services to allow insight into Wyoming State • Eliminated coverage of nursing facility reserve bed days documented changes in utilization & Hospital Title 25 • Revised reimbursement methodology for processing reimbursement trends Medicare crossover claims claims • Reduced coverage of adult dental services • Implemented a refined referral process to streamline the flow of information into • the Program Integrity unit, including the creation of a public website. Implemented the Fingerprint-Based April 1, 2017 Implemented 150% increase in drug Criminal Background Check (FCBC) new CMS rules manufacturer requirement, reviewing and verifying 228 for calculating rebate dollars after entities for compliance. Of these, 96 were reimbursement for consolidating drug identified as requiring FCBC completion. outpatient drugs rebate activities under single vendor Highlights and Initiatives • 7


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    WYOMING INTEGRATED NEXT GENERATION SYSTEM 1 2 PBMS SI-ESB Pharmacy Benefit System Integrator with Management System Enterprise Service Bus Processes pharmacy point- Connects all modules of-sale claims and handles together into an pharmacy related prior enterprise system authorizations CCMS 8 Care/Case Management System DW-BI Data Warehouse with Business Intelligence 3 Tools Develops & monitors plans Serves as data storage of care, captures & monitors for all other modules with assessments, screenings, treatment plans, and is replacing the current tools used to compile reports and analyze the Medicaid authorizes services Medicaid Management program Information System (MMIS) through the FWA BMS Fraud, Waste, Abuse Benefit Management procurement of these Analytics & Case Tracking Services separate modules Supports identification, Includes Medicaid over the next investigation, and claims processing collection of fraud, 2 to 3 years 7 and benefit plan management PRESM TPL waste, & abuse of Medicaid services by providers 4 Provider Enrollment, Third Party Liability and clients Screening, and Monitoring Ensure proper coordination Supports provider enrollment exists between Medicaid and through an electronic self- any other entity/individual service solution, verifies with obligation to provide provider licensing, and financial support for reviews/maintains all provider Medicaid services enrollments Modules A, B, & C 6 5 are consulting services to support the WINGS project throughout the transition to the new system A Testing & Quality B Independent C Business Process Assurance/Quality Verification & Re-Engineering & Optimization Control Services Validation Assists in streamlining processes to achieve Ensures each project module Certifies system meets cost reductions, enhance quality of Medicaid functions correctly all requirements & fulfills services, and increase efficiency intended purpose 8 • Highlights and Initiatives


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    SFY 2017 Performance SFY 2017: A Closer Look This section provides more detail on the performance of Wyoming Medicaid in SFY 2017, comparing enrollment, expenditures, and recipient counts across the past six years. ENROLLMENT SFY 2017 saw a decrease in enrollment of 4.6 percent from the previous SFY, with 84,649 unique individuals enrolled 84,785 members enrolled at any point at any time during the SFY. during the SFY with 63,247 Individuals may gain and lose eligibility several times members enrolled on average throughout the SFY. While some individuals may be each month eligible for a portion of the year, others retain eligibility throughout the year. As such, the distinct count of enrolled individuals for Medicaid for a complete SFY – regardless of how long they were enrolled – is greater than a point-in-time count of Medicaid enrollment. The table below compares the average monthly enrollment with the distinct count of enrolled members for each SFY. Unique Enrollment Average Monthly Enrollment Table 5. Change in Medicaid Enrollment 100,000 SFY SFY SFY SFY SFY SFY 89,328 89,684 88,642 91,062 88,775 2012 2013 2014 2015 2016 2017 90,000 84,785 Unique Enrollment 89,328 89,684 88,642 91,062 88,775 84,785 % Change from 80,000 -- 0.4% -1.2% 2.7% -2.5% -4.5% 74,628 Previous SFY 69,610 69,479 70,389 Average Monthly 66,696 69,610 69,479 70,389 74,628 66,696 63,247 70,000 Enrollment 63,247 % Change from -- -0.2% 1.3% 6.0% -10.6% -5.2% 60,000 Previous SFY SFY SFY SFY SFY SFY SFY Average Length of 9.3 9.2 9.5 9.9 9.2 9.2 2012 2013 2014 2015 2016 2017 Enrollment (months) Figure 2. Enrollment History: Unique and Monthly Average 78,000 76,000 SFY 2015 74,372 74,000 SFY 2015 72,000 69,940 SFY 2016 70,000 68,797 68,000 SFY 2016 66,000 64,624 64,000 SFY 2017 62,000 64,653 SFY 2017 60,000 61,904 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun SFY 2015 SFY 2016 SFY 2017 Figure 3. Monthly Medicaid Enrollment by State Fiscal Year SFY 2017: A Closer Look • 9


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    Medicaid enrolled members reside in every county in Wyoming, with more than half residing in 5 counties: Laramie (17 percent), Natrona (15 percent), Fremont (11 percent), Sweetwater and Campbell (7 percent each). County 'Other' indicates individuals who were at one time enrolled in Medicaid, but have moved out of state. Member county of residence is based on the address on file at the time the data is extracted. Table 6. Medicaid Enrollment by County Enrolled Percent of Park Sheridan County Crook Campbell Members Total Albany 3,671 4.3% Big Horn Johnson Big Horn 2,122 2.5% Washakie Campbell 6,300 7.4% Teton Weston Hot Springs Carbon 2,115 2.5% Niobrara Converse 1,887 2.2% Fremont Crook 837 1.0% Natrona Converse Fremont 9,700 11.4% Sublette Goshen 1,960 2.3% Goshen Platte Hot Springs 898 1.1% Johnson 927 1.1% Lincoln Laramie 14,216 16.8% Sweetwater Carbon Lincoln 1,968 2.3% Uinta Albany Laramie Natrona 13,006 15.3% Niobrara 335 0.4% 9,700-14,216 3,671-6,300 2,115-3,626 1,435-1,968 919-1,177 335-898 Other 2,430 2.9% Figure 4. Wyoming County Map by Medicaid Enrollment Park 3,626 4.3% Platte 1,169 1.4% Sheridan 3,782 4.5% Sublette 753 0.9% Sweetwater 6,090 7.2% Teton 1,435 1.7% Uinta 3,462 4.1% Washakie 1,177 1.4% Weston 919 1.1% Total 84,785 10 • SFY 2017: A Closer Look


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    EXPENDITURES In SFY 2017, the amount paid to providers remained relatively stable with a slight increase of 0.1 percent $555,419,725 total paid to providers from SFY 2016. $650,000,000 $554,583,138 $555,419,725 $517,257,164 $517,622,524 $527,531,608 $550,000,000 $500,931,031 $450,000,000 $350,000,000 $250,000,000 SFY SFY SFY SFY SFY SFY 2012 2013 2014 2015 2016 2017 Figure 5. Expenditure History As providers have up to one year from the date of service to submit claims to Medicaid for reimbursement, these expenditures include payments for services rendered prior to the start of SFY 2017. Table 7. Expenditure History by Service Type SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Medical $274,176,580 $283,615,999 $284,761,312 $300,054,010 $303,594,435 $296,606,571 Long-Term Care $209,162,712 $216,353,891 $215,466,756 $208,759,250 $230,992,217 $239,788,830 Dental $13,561,177 $13,272,110 $13,391,934 $14,473,863 $15,450,029 $14,167,617 Vision $3,192,131 $3,389,793 $3,464,394 $3,595,216 $3,652,188 $3,850,574 Other $838,430 $625,371 $538,127 $649,268 $894,268 $1,006,133 Figure 6, below, shows how SFY 2017 paid expenditures compared to SFY 2016 for top services. Only services with over $5 million in expenditures in either SFY have been included in the figure. More detailed information on services is available in the Services section of this report. 100.00 0% 6% 90.00 80.00 -10% SFY 2016 SFY 2017 70.00 3% 60.00 2% 50.00 40.00 -12% -6% 30.00 6% 20.00 0% -8% 3% 1% 10% 3% 42% 3% 10.00 55% 57% 25% -31% 0.00 Figure 6. Change in Expenditures from SFY 2016 to SFY 2017 for Top Services SFY 2017: A Closer Look • 11


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    RECIPIENTS In SFY 2017, the number of enrolled members who had claims paid during the year increased minimally by 0.1 percent from the previous SFY. Figure 7, below, shows the comparison between service utilization and 75,921 enrolled members expenditures; while 95 percent of recipients used Medical services, these with claims paid only accounted for 53 percent of total Medicaid expenditures. 80,000 78,000 75,968 76,275 76,318 75,921 75,284 74,792 76,000 74,000 72,000 70,000 SFY SFY SFY SFY SFY SFY 2012 2013 2014 2015 2016 2017 Figure 7. Recipient History Table 8. Recipient History by Service Type SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Medical 72,650 72,851 73,122 71,794 70,697 72,203 Long-Term Care 28,592 28,531 29,169 30,635 31,849 31,427 Dental 13,940 14,180 14,558 15,010 15,228 15,890 Vision 6,826 6,771 6,688 6,967 7,320 7,579 Other 2,422 1,857 1,642 1,643 1,946 2,919 100% 95% 90% % of Unduplicated Recipients 80% 70% 60% 50% 41% 40% 30% 21% 20% 10% 10% 4% 0% Medical Long-Term Care Dental Vision Other Dental, 3% % of Total Expenditures Vision, 1% Other, Medical, 53% Long-Term Care, 43% 0.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 8. Recipient Utilization versus Expenditure Breakdown by Service Type 12 • SFY 2017: A Closer Look


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    Eligibility Categories Eligibility Categories Federal statutes define individuals who qualify for Medicaid coverage, with eligibility determined using Federal Poverty Level (FPL) guidelines, Supplemental Security Income (SSI) standards, or the 1996 Family Care income standard. The FPL guidelines and SSI standards are based on an index that changes each year. See Appendix C for more information. For this report, Medicaid enrolled members are presented in 11 eligibility categories. Aged, Blind, or Disabled Aged, Blind, or Disabled Employed Individuals with Disabilities (ABD EID) Intellectually Disabled, Developmentally Disabled, • Employed individuals with disabilities or Acquired Brain Injury (ABD ID/DD/ABI) • Must pay a premium • Children and adults with an intellectual or developmental disability or • No SSI eligibility requirement an acquired brain injury • Income requirement based on SSI standards • No SSI eligibility requirement • Income requirement based on SSI standards Aged, Blind, or Disabled Institution • Includes residents living in the Intermediate Care Facility • Residents living in the hospital or Wyoming for the Intellectually Disabled (ICF-ID) (State training school/ state hospital (age 65 and older) Wyoming Life Resource Center) • Resources taken into consideration • No SSI eligibility requirement Aged, Blind, or Disabled Long-Term Care (ABD LTC) • Income requirement based on SSI standards • Includes the following individuals: • Adults in need of nursing facility level of care, but who have elected to receive services and supports in their home or community Aged, Blind, or Disabled • Residents of a nursing home Supplemental Security Income (ABD SSI) • Adults and children receiving hospice care • Disabled individuals receiving SSI automatically qualify • Resources taken into consideration • An individual no longer receiving SSI payment • No SSI eligibility requirement may be eligible using SSI criteria • Income requirement based on SSI standards Adults • Adult caretaker relatives with a dependent child; must Non-Citizens with Medicare Savings cooperate with child support enforcement; income Medical Emergencies • Medicare individuals not eligible for requirement based on set values • Non-citizen who other Medicaid programs • Newly eligible adults with income requirement based on meets all Medicaid • Qualified Medicare Beneficiary (QMB) Federal Poverty Level eligibility factors has resources taken into consideration • Individuals who age out of foster care when they except citizenship and income requirement based on FPL become 18 years old. As of January 1, 2014, former and social security Covers premiums, deductibles, and cost foster care individuals remain eligible until age 26. number sharing • Presumptive eligibility available for immediate, • Emergency services • Specified Low-Income Medicare temporary coverage and childbirth only Beneficiaries and Qualified Individuals have income requirement based on FPL. Covers Medicare premiums only Children • Newborns are automatically eligible if the mother is eligible for Medicaid at the time of birth Pregnant Women • Children with a Medicaid eligible caretaker; income requirement based on FPL and • Women with income below the 1996 dependent on child's age Family Care Standard must cooperate • Children with severe mental health needs in establishing paternity for the baby, • Foster care children are automatically eligible when in the Department of Family so Medicaid can pursue medical Services (DFS) custody, including some children who enter subsidized adoption. WDH support also covers medical services for children in foster care who are not eligible for Medicaid, • Presumptive eligibility available for using state funds tracked separately immediate, temporary coverage • Presumptive eligibility available for immediate, temporary coverage • Income requirement based on FPL Special Groups • Breast and Cervical Cancer Treatment Program for uninsured women with breast or cervical cancer; income requirement based on FPL; presumptive eligibility available for immediate, temporary coverage • Pregnant by Choice Waiver provides family planning services for individuals who received Medicaid benefits through the Pregnant Women program • Tuberculosis program for individuals diagnosed with tuberculosis; resources are taken into consideration, and income requirement based on SSI Figure 9. Eligibility Category Descriptions Eligibility Categories • 13


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    Table 9. Eligibility Category Summary % Change % Change % Change Enrolled Unique Eligibility Category from SFY from SFY Expenditures from SFY Members Recipients 2016 2016 2016 ABD EID 491 3 514 8 $4,444,205 -6 ABD ID/DD/ABI 2,641 1 2,661 1 $144,912,157 -1 ABD Institution 75 -3 109 12 $2,806,510 -29 ABD LTC 4,866 5 5,064 6 $133,737,121 5 ABD SSI 7,087 1 6,355 5 $54,964,847 1 Adults 11,781 -5 10,273 4 $40,492,988 -4 Children 50,999 -6 46,242 1 $140,647,477 -2 Medicare Savings Programs 4,973 0 2,872 -1 $3,206,357 -22 Non-Citizens with Medical Emergencies 293 -32 252 2 $1,040,454 -14 Pregnant Women 4,748 -14 5,298 -3 $26,246,328 8 Screenings & Gross Adjustments -- -- -- -- $1,405,708 174 Special Groups 163 -35 132 -11 $1,515,573 -19 Total 84,491 -5 75,920 2 $555,419,725 0 The figure below illustrates the distribution of members across the eligibility categories compared to the expenditures for those categories. While children represented 60% of all enrolled members for SFY 2017, the expenditures for children receiving services only accounted for 25% of total Medicaid expenditures. The ABD ID/DD/ABI and ABD LTC populations accounted for 9% of all enrolled members for the SFY but 50% of total Medicaid expenditures. Special Groups, 0.2% Special Groups, 0.3% 100% Pregnant Women, 6% Pregnant Women, 5% Non-Citizens Non-Citizens w/ Med Emerg, w/ Med Medicare Savings 90% 0.3% Emerg, 0.2% Programs, 6% Medicare Savings Programs, 0.6% Children, 25% 80% 70% Adults, 7% 60% Children, 60% ABD SSI, 10% 50% 40% ABD LTC, 24% 30% Adults, 14% ABD Institution, 0.5% 20% ABD SSI, 8% ABD ID/DD/ABI, 26% 10% ABD LTC, 6% ABD Institution, 0.1% ABD ID/DD/ABI, 3% ABD EID, 0.6% ABD EID, 0.8% 0% Enrolled Members Expenditures Figure 10. Enrolled Members versus Expenditures by Eligibility Category 14 • Eligibility Categories


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    Table 10. Enrollment History by Eligibility Category 5 Year Eligibility Category SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change ABD EID 309 350 341 360 479 496 61 ABD ID/DD/ABI 2,427 2,437 2,402 2,480 2,609 2,640 9 ABD Institution 78 86 71 76 77 80 3 ABD LTC 4,149 4,184 4,176 4,378 4,643 4,885 18 ABD SSI 7,331 7,389 7,134 7,052 7,039 7,117 -3 Adults 8,091 7,925 8,719 10,998 12,431 11,825 46 Children 57,196 57,061 56,079 57,007 54,345 51,164 -11 Medicare Savings Programs 4,746 5,032 5,167 5,338 4,982 4,994 5 Non-Citizens with Medical 776 953 949 794 432 292 -62 Emergencies Pregnant Women 5,704 5,633 5,400 5,743 5,517 4,778 -16 Special Groups 1,524 1,451 1,120 694 250 164 -89 Total 89,328 89,684 88,642 91,062 88,775 84,785 -5 Figure 11, below, shows how the breakdown of enrollment by eligibility category has changed over time. Most eligibility categories have maintained a steady percentage of the Medicaid population, however, Adults and Children have seen broader shifts, from 9% and 64%, respectively in SFY 2012 to 14% and 60% in SFY 2017. 100% Special Groups, 0.2% Pregnant Women, 6% 90% Medicare Savings Programs, 6% Non-Citizens with Medical Emergencies, 0.3% 80% 70% 60% Children, 60% 50% 40% 30% Adults, 14% 20% ABD SSI, 8% 10% ABD Institution, 0.1% ABD LTC, 6% ABD ID/DD/ABI, 3% 0% ABD EID, 0.6% SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Figure 11. Enrollment History by Eligibility Category Eligibility Categories • 15


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    Table 11. Expenditures History by Eligibility Category 5 Year Eligibility Category SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change ABD EID $3,208,536 $4,589,792 $4,545,872 $3,795,205 $4,730,644 $4,444,205 39 ABD ID/DD/ABI $131,305,592 $140,008,570 $140,255,339 $137,112,834 $146,523,597 $144,912,157 10 ABD Institution $4,975,050 $4,836,583 $6,947,121 $3,843,309 $3,976,596 $2,806,510 -44 ABD LTC $115,028,538 $111,411,633 $109,585,095 $109,685,023 $127,126,736 $133,737,121 16 ABD SSI $51,345,795 $52,203,560 $53,252,515 $57,532,693 $54,218,689 $54,964,847 7 Adults $28,827,439 $28,446,023 $28,414,259 $39,268,780 $42,070,572 $40,492,988 40 Children $124,839,646 $133,149,744 $135,754,662 $143,624,614 $144,048,715 $140,647,477 13 Medicare Savings $3,245,880 $3,708,394 $4,086,134 $4,564,069 $4,098,086 $3,206,357 -1 Programs Non-Citizens with $1,948,889 $1,892,640 $1,490,032 $1,236,724 $1,212,043 $1,040,454 -47 Medical Emergencies Pregnant Women $32,051,842 $31,815,394 $28,762,228 $24,134,468 $24,192,832 $26,246,328 -18 Screenings & Gross $355,924 $378,465 $389,686 $183,197 $512,743 $1,405,708 295 Adjustments Special Groups $3,797,900 $4,816,363 $4,139,581 $2,550,692 $1,871,886 $1,515,573 -60 Total $500,931,031 $517,257,164 $517,622,524 $527,531,608 $554,583,138 $555,419,725 11 $160,000,000 -1% -2% Figure 12 shows how expenditures $140,000,000 5% have changed from the previous SFY 2016 SFY 2017 SFY for each eligibility category. $120,000,000 $100,000,000 While most populations experienced a decrease in $80,000,000 expenditures, increases occurred $60,000,000 1% for Long-Term Care, SSI, Pregnant -4% Women, and Screenings and Gross $40,000,000 8% Adjustments, with the increase for $20,000,000 the latter being primarily due to gross adjustments. $0 ABD Children ABD LTC ABD SSI Adults Pregnant ID/DD/ABI Women $5,000,000 -6% $4,500,000 Figure 13, on the next page, shows -22% -29% how the changes in Expenditures $4,000,000 compares to the change in $3,500,000 Recipients from SFY 2016 to $3,000,000 SFY 2017. Note, an increase $2,500,000 in recipients served does not -19% necessarily involve an increase in $2,000,000 $1,500,000 174% -14% spending. $1,000,000 $500,000 $0 ABD EID Medicare ABD Special Screenings & Non-Citizens Savings Institution Groups Gross Adj w/ Med Emerg Figure 12. Change in Expenditures from SFY 2016 to SFY 2017 by Eligibility Category 16 • Eligibility Categories


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    The table below displays a distinct count of recipients for each eligibility category, as well as the total distinct count of recipients. Summing the recipients for each eligibility category will not match the total recipients as individuals may receive services under multiple eligibility categories throughout the SFY. Table 12. Unique Recipient History by Eligibility Category 5 Year Eligibility Category SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change ABD EID 310 342 345 360 475 514 66 ABD ID/DD/ABI 2,431 2,448 2,407 2,476 2,636 2,661 9 ABD Institution 119 100 92 91 97 109 -8 ABD LTC 4,433 4,401 4,386 4,523 4,792 5,064 14 ABD SSI 6,191 6,245 6,269 6,125 6,048 6,355 3 Adults 6,590 6,683 6,907 8,466 9,867 10,273 56 Children 49,110 49,039 49,407 47,608 45,958 46,242 -6 Medicare Savings 2,514 2,641 2,762 2,984 2,908 2,872 14 Programs Non-Citizens with 426 414 367 287 248 252 -41 Medical Emergencies Pregnant Women 5,785 5,939 5,509 5,469 5,443 5,298 -8 Special Groups 686 622 497 271 148 132 -81 Total 75,968 76,275 76,318 75,284 74,783 75,920 0 10% Change in Expenditures Change in Recipients 8% 8% 6% 6% 5% 5% 4% 4% 2% 1% 1% 1% 0% -2% -1% -2% -3% -4% -4% -6% ABD ID/DD/ABI Children ABD LTC ABD SSI Adults Pregnant Women 15% 12% 10% 8% 5% 2% 0% -5% -1% -10% -6% -15% -11% -14% -20% -19% -25% -22% -30% -29% -35% ABD EID Medicare Savings ABD Institution Special Groups Non-Citizens w/ Med Emerg Figure 13. Change in Expenditures and Recipients from SFY 2016 to SFY 2017 by Eligibility Category Eligibility Categories • 17


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    Services Services Medicaid provides a wide range of covered medical, behavioral and long-term care services. Some recipients receive full benefits while others receive partial or limited benefits. Medicaid covers mandatory services as required by the federal government and optional services authorized by the Wyoming Legislature. Rate information and reimbursement methodology and history are available in Appendix B. OVERVIEW Wyoming Medicaid covers the following mandatory9 and optional services. These service areas are explained in further detail later in this report. Table 13. Covered Services Service Adults Children (Under Age 21) Acquired Brain Injury Waiver Optional Optional Ambulance Mandatory Mandatory Ambulatory Surgical Center Optional Optional 10 Behavioral Health Optional Mandatory (EPSDT) Care Management Entity / Children's Mental Health Waiver N/A Optional Clinic Services Optional Mandatory (EPSDT) Comprehensive and Supports Waivers for Persons with ID/DD/ABI Optional Optional 11 Community Choices Waiver Optional N/A Dental Optional Mandatory (EPSDT) Durable Medical Equipment Optional Mandatory (EPSDT) End Stage Renal Disease Optional Mandatory (EPSDT) Federally Qualified Health Centers Mandatory Mandatory Home Health Mandatory Mandatory Hospice Optional Optional Hospital Mandatory Mandatory ICF-ID Optional Optional Laboratory / X-Ray Mandatory Mandatory Nursing Facility Mandatory Mandatory Program for All-Inclusive Care of the Elderly (PACE) Optional N/A Pharmacy Optional Mandatory (EPSDT) Physician and Other Practitioner Mandatory Mandatory Pregnant by Choice Waiver Optional N/A Psychiatric Residential Treatment Facility (PRTF) N/A Mandatory (EPSDT) 12 Physical/Occupational/Speech Therapies Optional Mandatory (EPSDT) Public Health, Federal13 Mandatory Mandatory Public Health or Welfare Optional Mandatory (EPSDT) Rural Health Clinic Mandatory Mandatory Vision Optional Mandatory (EPSDT) 9 These services are required for children to comply with Early Prevention, Screening, Detection, and Treatment (EPSDT) requirements. EPSDT services are operated under the Health Check program, discussed in more detail in the Subprograms section. 10 Excludes the Children's Mental Health Waiver and Psychiatric Residential Treatment Facility. 11 Some services in these waivers may be mandatory if the child is otherwise eligible for Medicaid without the waiver. 12 Physical/Occupational/Speech Therapies service detail is included in the Physician and Other Practitioner data in the detail section of this report. 13 Refers to Indian Health Services and Tribal 638 facilities. Services • 19


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    Table 14. Service Utilization Summary % Change % Change % Change Expenditures per Service Expenditures from SFY Recipients15 from SFY from SFY Recipient 2016 2016 2016 Ambulance $3,847,375 8 3,614 10 $1,065 -2 Ambulatory Surgical Center $4,095,973 -31 3,328 -2 $1,231 -30 Behavioral Health $30,797,112 -12 13,175 4 $2,338 -15 16 Care Management Entity (CME) $7,135,148 42 485 42 $14,712 0 Clinic/Center $1,327,800 -3 1,431 -6 $928 4 Dental $14,167,617 -8 31,427 -1 $451 -7 DME, Prosthetics/Orthotics/Supplies $9,029,583 10 7,420 5 $1,217 5 End Stage Renal Disease $1,267,034 34 145 13 $8,738 18 Federally Qualified Health Center $5,725,094 55 4,670 36 $1,226 14 Home Health $9,596,803 1 714 -2 $13,441 4 Hospice $1,316,838 30 224 14 $5,879 14 Hospital Total $98,467,703 -9 39,746 -3 $2,477 -6 Inpatient $71,022,272 -10 10,142 6 $7,003 -15 Outpatient $27,373,462 -6 37,282 -4 $734 -2 Other Hospital $71,969 -49 239 36 $301 -63 Intermediate Care Facility-ID $19,204,867 6 66 -6 $290,983 12 Laboratory $844,218 -45 8,015 -16 $105 -35 Nursing Facility $87,001,112 6 2,552 7 $34,091 -1 Other $1,006,133 13 2,919 50 $345 -25 PACE $3,520,283 20 141 21 $24,967 0 Physician & Other Practitioner $60,013,763 3 63,894 4 $939 -1 Prescription Drug $49,445,160 2 42,757 -3 $1,156 5 PRTF $12,121,830 3 296 -1 $40,952 3 Public Health or Welfare $912,444 -15 5,654 -6 $161 -10 Public Health, Federal $8,718,888 3 3,506 3 $2,487 0 Rural Health Clinic $1,540,607 9 4,542 24 $339 -12 Vision $3,850,574 5 15,890 4 $242 1 Waiver Total $120,465,765 2 4,954 3 $24,317 -1 Acquired Brain Injury $6,960,893 3 162 -1 $42,968 4 Adult ID/DD $1,565 -7 1 -50 $1,565 87 Community Choices $4,187,866 25 278 9 $15,064 15 Comprehensive $88,527,446 0 1,863 -3 $47,519 4 Supports $4,378,255 57 540 27 $8,108 24 Total $555,419,725 0 75,921 2 $7,316 -1 14 This table displays a unique count of recipients for each service area, as well as the total unique count of recipients for all of Medicaid. Summing the recipients for each year across all service areas will not equal the total recipients shown as recipients often receive multiple services through the SFY. 15 The Care Management Entity service includes $310,174 in expenditures paid for 20 children while enrolled in non-Medicaid state-funded institutional foster care. 20 • Services


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    100% Total expenditures for all Medicaid services remained steady with a minimal 0.2% increase 90% Other Services, 20% from SFY 2016 for a total of $555,419,725. 80% The top services based on expenditures in SFY Behavioral Health, 6% 2017 are Waivers16, Hospital, Nursing Facility and 70% Prescription Drug, 9% Physician & Other Practitioner. 60% Physician & Other Practitioner, 11% Behavioral Health -12% 50% Nursing Facility, 16% Prescription Drug 2% 40% Physician & Other Practitioner 3% 30% Hospital Total, 18% Nursing Facility 6% 20% Hospital Total -9% 10% Waivers, 22% Waiver Total 2% 0% % of Total Expenditures -12% -9% -6% -3% 0% 3% 6% Figure 15. Percent of Total Expenditures by Service Figure 16. Change in Expenditures for Top Services The total unique recipient count for all Medicaid services increased by 1.5% from the previous year to 75,921 individuals, with Physician and Other Practitioner, Prescription Drug, and Hospital as the top services. The figure below shows the percentage of unduplicated Medicaid recipients using each service. In SFY 2017 84% of Medicaid recipients had claims for Physician & Other Practitioner services, 56% had prescription drug claims, and so on. 90% 84% 80% 70% 60% 56% 52% 50% 41% 40% 30% 21% 17% 20% 11% 10% 7% 10% 7% 6% 6% 5% 5% 4% 4% 3% 2% 1% 1% 0% 0% 0% 0% 0% 0% Figure 14. Percent of Total Unduplicated Recipients by Service 16 Includes waiver services expenditures only, and does not account for non-waiver medical services utilized by waiver recipients. Services • 21


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    Table 15. Expenditure History by Service 5 Year Service SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Ambulance $3,459,400 $3,606,360 $3,760,537 $4,352,067 $3,571,623 $3,847,375 11 Ambulatory Surgical $2,822,957 $3,439,188 $4,039,944 $6,090,776 $5,953,159 $4,095,973 45 Center Behavioral Health $26,125,428 $28,354,676 $30,602,969 $33,879,362 $34,964,154 $30,797,112 18 Care Management Entity17 -- -- -- -- $5,021,978 $7,135,148 n/a Clinic/Center $1,195,547 $1,166,813 $1,295,561 $1,339,630 $1,361,953 $1,327,800 11 Dental $13,561,177 $13,272,110 $13,391,934 $14,473,863 $15,450,029 $14,167,617 4 DME, Prosthetics/ $7,270,213 $7,730,289 $7,627,734 $8,624,246 $8,200,062 $9,029,583 24 Orthotics/Supplies End Stage Renal Disease $1,233,755 $1,343,669 $1,071,750 $1,099,569 $948,612 $1,267,034 3 Federally Qualified Health $1,550,274 $2,018,911 $2,698,283 $3,259,793 $3,689,548 $5,725,094 269 Center Home Health $2,963,510 $2,897,016 $3,533,728 $4,618,885 $9,467,835 $9,596,803 224 Hospice $983,026 $1,082,188 $1,468,295 $1,157,101 $1,014,959 $1,316,838 34 Hospital Total $105,798,987 $108,839,452 $101,931,277 $104,523,947 $107,692,150 $98,467,703 -7 Inpatient $77,130,425 $78,462,603 $72,932,440 $73,407,132 $78,575,068 $71,022,272 -8 Outpatient $28,657,373 $30,189,391 $28,703,147 $31,056,066 $28,975,050 $27,373,462 -4 Other Hospital $11,189 $187,458 $295,690 $60,748 $142,031 $71,969 543 Intermediate Care $10,065,657 $17,942,326 $19,152,530 $18,091,427 $18,193,221 $19,204,867 91 Facility-ID18 Laboratory $1,100,774 $1,149,473 $1,284,678 $1,516,042 $1,536,310 $844,218 -23 Nursing Facility $73,805,803 $73,593,462 $72,866,933 $70,354,260 $82,445,811 $87,001,112 18 Other $838,430 $625,371 $538,127 $649,268 $894,268 $1,006,133 20 PACE -- $168,398 $1,288,934 $2,242,570 $2,934,877 $3,520,283 n/a Physician & Other $62,845,816 $62,856,989 $62,372,535 $61,249,367 $58,278,406 $60,013,763 -5 Practitioner Prescription Drug $41,914,658 $39,110,022 $41,238,663 $47,946,923 $48,597,364 $49,445,160 18 PRTF $8,019,118 $12,080,494 $14,886,133 $13,575,847 $11,797,657 $12,121,830 51 Public Health or Welfare $988,455 $924,007 $962,164 $1,009,814 $1,072,715 $912,444 -8 Public Health, Federal $7,240,130 $8,067,975 $7,999,556 $8,761,358 $8,479,944 $8,718,888 20 Rural Health Clinic $1,628,043 $1,845,491 $1,521,233 $1,668,167 $1,413,842 $1,540,607 -5 Vision $3,192,131 $3,389,793 $3,464,394 $3,595,216 $3,652,188 $3,850,574 21 Waiver Total $122,327,742 $121,752,688 $118,624,631 $113,452,108 $117,950,473 $120,465,765 -2 Acquired Brain Injury $6,925,596 $7,679,811 $7,371,614 $6,636,440 $6,748,171 $6,960,893 1 Adult ID/DD $84,846,084 $84,204,861 $83,501,095 $16,541,190 $1,674 $1,565 -100 Child ID/DD $13,646,013 $13,301,942 $11,415,264 $8,372,841 $179,173 -- -100 Children's Mental $942,386 $688,995 $527,514 $732,257 $61,981 -- -100 Health Community Choices $15,738,474 $15,877,079 $15,763,707 $16,630,675 $19,801,419 $20,597,605 31 Comprehensive -- -- $44,982 $63,719,016 $88,377,607 $88,527,446 n/a Supports -- -- $454 $819,690 $2,780,450 $4,378,255 n/a Total $500,931,031 $517,257,164 $517,622,524 $527,531,608 $554,583,138 $555,419,725 11 17 The Care Management Entity service includes expenditures paid for non-Medicaid children in state-funded institutional foster care. 18 For SFY 2012 only Federal portion of expenditures are shown. 22 • Services


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    Table 16. Expenditure History by Other19 Service 5 Year Service SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Ambulatory Family Planning $81,564 $68,988 $71,213 $69,754 $55,497 $62,853 -23 Facility Case Management $219,942 $196,574 $193,913 $297,117 $254,740 $409,938 86 Chiropractor $7,349 $7,500 $5,661 $6,347 $99,664 $280,207 3,713 Day Training, Developmentally $57,158 $71,266 $79,578 $27,476 $52,304 $58,362 2 Disabled Service Dietitian, Registered -- -- -- -- -- $391 n/a Interpreter $48,321 $43,529 $38,171 $56,339 $47,205 $32,056 -34 Lodging -- -- -- -- -- $53,950 n/a Pace PPL -- -- -- $0 -$80 $0 n/a Phlebotomy/WY Health Fair $5,910 $2,635 $5,870 $1,920 $575 -- n/a Radiology: Mobile $109,250 $4,081 $226 $52 $7 -- n/a Rehabilitation, Comprehensive Outpatient Rehabilitation Facility $125,928 $121,618 $143,525 $154,682 $146,226 $84,406 -33 (CORF) Residential Treatment Facility For $183,009 $109,220 -- $35,712 $237,904 -- n/a Emotionally Disturbed Taxi -- -- -- -- -- $16,674 n/a Transportation Service -- -- -- -- -- $7,329 n/a Unclassified -- -$39 -$30 -$131 $225 -$33 n/a Total $838,430 $625,371 $538,127 $649,268 $894,268 $1,006,133 20 19 This table shows services that fall outside the criteria ranges used to define other service areas for this report, as defined by pay to provider taxonomy. Services • 23


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    Table 17. Recipient Count20 History by Service 5 Year Service SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Ambulance 3,604 3,433 3,517 3,506 3,280 3,614 0 Ambulatory Surgical Center 3,088 3,259 3,392 3,537 3,409 3,328 8 Behavioral Health 10,674 11,410 11,294 12,285 12,686 13,175 23 21 Care Management Entity -- -- -- -- 342 485 n/a Clinic/Center 1,623 1,465 1,520 1,589 1,529 1,431 -12 Dental 28,592 28,531 29,169 30,635 31,849 31,427 10 DME, Prosthetics/Orthotics/ 7,245 7,364 7,122 7,319 7,084 7,420 2 Supplies End Stage Renal Disease 98 110 106 107 128 145 48 Federally Qualified Health 2,722 3,612 4,034 5,987 3,438 4,670 72 Center Home Health 582 591 590 686 730 714 23 Hospice 135 179 251 179 197 224 66 Hospital Total 44,107 42,666 40,033 42,464 40,800 39,746 -10 Inpatient 10,890 10,970 10,293 10,599 9,570 10,142 -7 Outpatient 41,772 40,147 37,618 40,150 38,664 37,282 -11 Other Hospital 104 142 194 148 176 239 130 Intermediate Care Facility-ID 84 81 79 75 70 66 -21 Laboratory 9,415 9,724 9,490 8,830 9,540 8,015 -15 Nursing Facility 2,410 2,445 2,384 2,342 2,388 2,552 6 Other 2,422 1,857 1,642 1,643 1,946 2,919 21 PACE -- 22 63 95 117 141 n/a Physician & Other Practitioner 63,695 61,515 65,284 62,816 61,460 63,894 0 Prescription Drug 48,222 47,607 44,464 46,031 43,927 42,757 -11 PRTF 274 328 338 332 298 296 8 Public Health or Welfare 6,466 6,238 5,772 5,967 5,989 5,654 -13 Public Health, Federal 3,249 4,222 3,546 3,382 3,414 3,506 8 Rural Health Clinic 4,174 5,418 4,670 4,530 3,664 4,542 9 Vision 13,940 14,180 14,558 15,010 15,228 15,890 14 Waiver Total 4,302 4,207 4,168 4,443 4,822 4,954 15 Acquired Brain Injury 188 186 181 168 163 162 -14 Adult ID/DD 1,380 1,395 1,409 1,325 2 1 -100 Child ID/DD 773 761 699 659 148 -- -100 Children's Mental Health 131 82 57 79 40 -- -100 Community Choices 1,891 1,841 1,870 2,034 2,286 2,410 27 Comprehensive -- -- 3 1,755 1,925 1,863 n/a Supports -- -- 0 191 425 540 n/a Total 75,968 76,275 76,318 75,284 74,792 75,921 0 20 This table displays a unique count of recipients for each service area, as well as the total unique count of recipients for all of Medicaid. Summing the recipients for each year across all service areas will not equal the total recipients shown as recipients often receive multiple services through the SFY. 21 The Care Management Entity service recipient count includes non-Medicaid children in state-funded institutional foster care. 24 • Services


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    SERVICE DETAILS This section provides a detailed view of the services presented in the overview. Services are defined by the taxonomy of the provider paid for the service. AMBULANCE Emergency ground and air transportation and limited non-emergency ground transportation $4,000,000 $3,847,375 3,614 h10% SFY 2017 3,750 h8% $3,500,000 $3,847,375 SFY 2017 $3,000,000 3,614 3,000 $2,500,000 of total of $2,000,000 0.7% Medicaid expenditures 2,250 5% Medicaid recipients Expenditures $1,500,000 Recipients 36% 1,500 $1,000,000 of Ambulance 24% of Ambulance 750 $500,000 SFY 2016 expenditures SFY 2016 recipients $3,571,623 for children 3,280 were children $0 0 0% 25% 50% 75% 100% 95% 100% 75% 50% 9% of Ambulance 25% 14% recipients used Expenditures 36% 64% Ground 0% both Air and Air Recipients Ground services Table 18. Ambulance Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Total Ambulance Services Expenditures $3,459,400 $3,606,360 $3,760,537 $4,352,067 $3,571,623 $3,847,375 11 Recipients 3,604 3,433 3,517 3,506 3,280 3,614 0 Expenditures per Recipient $960 $1,050 $1,069 $1,241 $1,089 $1,065 11 Air Ambulance Services Expenditures $1,892,961 $2,129,324 $2,291,183 $2,931,554 $2,310,149 $2,444,615 29 Recipients 396 426 505 553 476 509 29 Expenditures per Recipient $4,780 $4,998 $4,537 $5,301 $4,853 $4,803 0 Ground Ambulance Services Expenditures $1,562,840 $1,472,500 $1,467,922 $1,413,123 $1,250,084 $1,401,636 -10 Recipients 3,476 3,290 3,375 3,322 3,095 3,434 -1 Expenditures per Recipient $450 $448 $435 $425 $404 $408 -9 Services • 25


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    AMBULATORY SURGERY CENTERS Surgical procedures that do not require overnight inpatient hospital care. Encompasses all surgical procedures covered by Medicare, as well as procedures Medicaid has approved for provision as outpatient services. ASC services may also be provided in an outpatient hospital setting. $6,000,000 $4,095,973 3,328 i2% 3,500 $5,000,000 i31% 3,000 SFY 2017 3,328 $4,000,000 SFY 2017 of total 2,500 of $3,000,000 $4,095,973 0.7% Medicaid expenditures 2,000 5% Medicaid recipients Expenditures 1,500 Recipients $2,000,000 Total expenditures for outpatient hospital 1,000 and ASC services i10% $1,000,000 SFY 2016 SFY 2016 500 $5,953,159 3,409 from SFY 2016 $0 0 Table 19. Ambulatory Surgery Center Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $2,822,957 $3,439,188 $4,039,944 $6,090,776 $5,953,159 $4,095,973 45 Recipients 3,088 3,259 3,392 3,537 3,409 3,328 8 Expenditures per Recipient $914 $1,055 $1,191 $1,722 $1,746 $1,231 35 BEHAVIORAL HEALTH All services provided by Behavioral Health provider taxonomies $35,000,000 $30,797,112 13,175 h4% 14,000 $30,000,000 i12% 12,000 SFY 2017 SFY 2017 13,175 $30,797,112 of total of $25,000,000 6% Medicaid expenditures 10,000 17% Medicaid recipients $20,000,000 8,000 Expenditures i51% i6% $15,000,000 6,000 Recipients $10,000,000 4,000 in ID/DD/ABI in ID/DD/ABI behavioral health recipients $5,000,000 SFY 2016 2,000 SFY 2016 expenditures $34,964,154 12,686 $0 0 BEHAVIORAL HEALTH SERVICES FROM NON - BEHAVIORAL HEALTH PROVIDERS Additionally, non-behavioral health providers may provide behavioral health services, which are not included in the figures above. In SFY 2017, behavioral health expenditures paid to non-behavioral health providers increased by 2% to $1,265,657, while the number of behavioral health recipients who received behavioral health services from these providers increased by 7% to 4,560. 26 • Services


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    Table 20. Behavioral Health Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Behavioral Health Services Expenditures $26,125,428 $28,354,676 $30,602,969 $33,879,362 $34,964,154 $30,797,112 18 Recipients 10,674 11,410 11,294 12,285 12,686 13,175 23 Expenditures per Recipient $2,448 $2,485 $2,710 $2,758 $2,756 $2,338 -4 22 Non-Behavioral Health Provider Services Expenditures $1,428,438 $1,380,256 $1,392,647 $1,264,549 $1,241,688 $1,265,657 -11 Recipients 3,757 2,981 3,834 3,854 4,275 4,560 21 Expenditures per Recipient $380 $463 $363 $328 $290 $278 -27 A new policy took effect on January 1, 2017 instituting cap limits for adult recipients for specific behavioral health procedure codes, regardless of provider taxonomy. $8,000,000 1,600 Expenditures Recipients While most eligibility categories $7,000,000 $7,436,264 1,400 saw minimal change from SFY 2016, the ABD ID/DD/ $6,000,000 1,200 ABI population experienced a $5,000,000 $5,666,536 1,000 decrease in expenditures of 51% for Behavioral Health providers $4,000,000 800 and 50% for Behavioral Health $4,071,991 $3,000,000 $3,657,751 $3,659,761 600 services regardless of provider $3,302,617 type. Figure 17 shows how $2,000,000 400 behavioral health expenditures and recipients have changed for $1,000,000 200 the ABD ID/DD/ABI population $0 0 over the past five years. SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Figure 17. Behavioral Health Expenditures and Recipient History for ID/DD/ABI $6,000,000 $5,178,447 Age 0-20 Age 21-64 Age 65+ $5,000,000 $4,000,000 $3,067,611 $3,000,000 $2,682,487 $2,599,574 $2,524,443 $2,000,000 $1,000,000 $0 F33.2 - Major Depressive F43.20 - Adjustment F43.10 - Post-Traumatic F32.9 - Major Depressive F33.1 - Major Depressive Disorder Recurrent Severe Disorder Unspecified Stress Disorder Unspecified Disorder Single Episode Disorder Recurrent Mode w/o Psychotic Features Figure 18. Top Five Behavioral Health Diagnosis Codes by Expenditures for all Provider Types Table 21. Top Five Behavioral Health Diagnosis Codes by Expenditures for all Provider Types Diagnosis Code and Description Age 0-20 Age 21-64 Age 65+ Total F33.2 - Major Depressive Disorder Recurrent Severe w/o Psychotic Features $4,687,789 $455,855 $34,803 $5,178,447 F43.20 - Adjustment Disorder Unspecified $2,636,036 $409,016 $22,559 $3,067,611 F43.10 - Post-Traumatic Stress Disorder Unspecified $1,947,972 $721,278 $13,237 $2,682,487 F32.9 - Major Depressive Disorder Single Episode $1,203,316 $735,906 $660,352 $2,599,574 F33.1 - Major Depressive Disorder Recurrent Mode $1,436,574 $966,552 $121,318 $2,524,443 Total $11,911,686 $3,288,606 $852,269 $16,052,561 22 See Appendix B for additional information regarding the types of providers who provide Behavioral Health services. Services • 27


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    CARE MANAGEMENT ENTITY Provides intensive care coordination to children and youth with complex behavioral health conditions and their families, using a High Fidelity Wrap-around model to support their success in their homes, schools, and communities. Started in SFY 2016. $7,135,148 485 $7,000,000 h42% 500 SFY 2017 h42% $6,000,000 SFY 2017 $7,135,148 400 485 of total of $5,000,000 1% Medicaid expenditures 300 0.6% Medicaid EXPENDITURES $4,000,000 recipients $3,000,000 RECIPIENTS 200 $2,000,000 SFY 2016 100 $1,000,000 $5,021,978 SFY 2016 342 $0 0 Table 22. Care Management Entity Services Summary CME also provides services to children enrolled in SFY 2016 SFY 2017 non-Medicaid state-funded institutional foster care. The total SFY 2017 expenditures and recipient count Expenditures $5,021,978 $7,135,148 shown in Table 22 includes $310,174 for those 20 Recipients 342 485 children. Expenditures per Recipient $14,684 $14,712 CLINIC/CENTER Services for clients with developmental disabilities who qualify for programs, training, care, treatment, and supervision in a structured setting, provided by state or privately funded facilities. Services include diagnostic evaluations and assessments, physical, occupational, and speech therapies, and mental health services for clients age 5 and younger. $1,327,800 1,431 $1,500,000 i3% 1,500 i6% SFY 2017 $1,250,000 1,250 SFY 2017 1,431 of total of $1,000,000 $1,327,800 0.2% Medicaid expenditures 1,000 2% Medicaid EXPENDITURES $750,000 recipients 750 RECIPIENTS $500,000 500 SFY 2016 $250,000 $1,361,953 250 SFY 2016 1,529 $0 0 Table 23. Clinic/Center Services Summary 5 Year SFY 2011 SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 Percent Change Expenditures $1,195,547 $1,166,813 $1,295,561 $1,339,630 $1,361,953 $1,327,800 11 Recipients 1,623 1,465 1,520 1,589 1,529 1,431 -12 Expenditures per Recipient $737 $796 $852 $843 $891 $928 26 28 • Services


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    DENTAL Dental services are covered based on enrolled member's age, with the goal of ensuring access to dental care so recipients may avoid emergency dental situations by receiving preventive and routine dental services for overall oral health. $14,167,617 31,427 i8% i1% $15,000,000 35,000 SFY 2017 30,000 SFY 2017 $12,500,000 $14,167,617 of total 31,427 of $10,000,000 3% Medicaid expenditures 25,000 41% Medicaid recipients 20,000 $7,500,000 Expenditures 45% 15,000 Recipients $5,000,000 SFY 2016 10,000 of dental recipients $15,450,029 received services from $2,500,000 5,000 SFY 2016 31,849 a dental specialist $0 0 Although there are dental providers in most of Wyoming's 23 counties, dental specialists exist in only 10 (43%). 45% of dental recipients received services from a dental specialist in SFY 2017, with 10% receiving such services out of state. Table 24. Dental Services Summary 5 Year SFY 2011 SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 Percent Change Expenditures $13,561,177 $13,272,110 $13,391,934 $14,473,863 $15,450,029 $14,167,617 4 Recipients 28,592 28,531 29,169 30,635 31,849 31,427 10 Expenditures per Recipient $474 $465 $459 $472 $485 $451 -5 Services • 29


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    DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES Services covered when ordered by a physician or other licensed practitioner for home use to reduce an individual's physical disability and restore the individual to a functional level. $9,029,583 7,420 $10,000,000 h10% 8,000 7,000 h5% SFY 2017 SFY 2017 7,420 $7,500,000 $9,029,583 of total 6,000 of 1.6% Medicaid expenditures 5,000 10% Medicaid recipients EXPENDITURES $5,000,000 4,000 RECIPIENTS 3,000 $2,500,000 2,000 SFY 2016 SFY 2016 $8,200,062 1,000 7,084 $0 0 Medicaid covers rental of DME, and applies rental payments toward the purchase of the item when the cost of renting equals the cost of purchase, or at the end of 10 months of rental. Medicaid automatically purchases low cost items (i.e., less than $150) and caps all rental items, except oxygen concentrators and ventilators, at the purchase price. Medicaid also caps all per-day rentals at 100 days and monthly rentals at 10 months. Medicaid does not cover routine maintenance and repairs for rental equipment. See Appendix B for more information regarding equipment and supplies included in this service area. Table 25. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Total Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Services Expenditures $7,270,493 $7,890,382 $7,627,751 $8,630,652 $8,200,062 $9,029,583 24 Recipients 7,245 8,508 7,122 7,328 7,084 7,420 2 Expenditures per Recipient $1,004 $927 $1,071 $1,178 $1,158 $1,217 21 Durable Medical Equipment Services Only Expenditures $6,492,369 $7,062,121 $7,040,745 $7,910,490 $7,401,383 $8,272,343 27 Recipients 6,880 8,170 6,820 6,918 6,710 7,018 2 Expenditures per Recipient $944 $864 $1,032 $1,143 $1,103 $1,179 25 Prosthetics, Orthotics, and Supplies Services Only Expenditures $778,124 $828,261 $587,006 $720,162 $798,679 $757,241 -3 Recipients 673 651 587 743 624 664 -1 Expenditures per Recipient $1,156 $1,272 $1,000 $969 $1,280 $1,140 -1 $10,000,000 DME Only POS Only $9,029,583 $8,630,652 $8,200,062 $8,000,000 $7,890,382 $7,627,751 $7,270,493 $6,000,000 $4,000,000 $2,000,000 $0 SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Figure 19. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies History by Expenditures 30 • Services


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    END STAGE RENAL DISEASE All medically necessary services related to renal disease care, including inpatient renal dialysis and outpatient services related to ESRD treatment, as well as treatment if Medicare denies coverage for an enrolled member on a home dialysis program. Hospital or free-standing facility must be a certified ESRD facility. Personal care attendants are not covered for this program. $1,267,034 145 $1,400,000 h34% 150 SFY 2017 h13% $1,200,000 125 SFY 2017 145 $1,000,000 $1,267,034 of total of $800,000 0.2% Medicaid expenditures 100 0.2% Medicaid recipients EXPENDITURES 75 $600,000 RECIPIENTS 50 $400,000 SFY 2016 $200,000 $948,612 25 SFY 2016 128 $0 0 The majority of ESRD recipients are dual individuals, those enrolled in both Medicare and Medicaid. Medicare is the primary payer for End Stage Renal Disease (ESRD) services for dual individuals, and therefore most Medicaid ESRD expenditures are for Medicaid-only individuals. Medicare ESRD coverage may begin no later than the third month after the patient begins a course of dialysis treatment. During the 90-day Medicare eligibility determination period, Medicaid reimburses ESRD services for enrolled members and will reimburse services if Medicare denies eligibility. Wyoming also has a non-Medicaid state-funded ESRD program, which reimburses at Medicare rates. Table 26. End Stage Renal Disease Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $1,233,755 $1,343,669 $1,071,750 $1,099,569 $948,612 $1,267,034 3 Recipients 98 110 106 107 128 145 48 Expenditures per Recipient $12,589 $12,215 $10,111 $10,276 $7,411 $8,738 -31 Services • 31


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    FEDERALLY QUALIFIED HEALTH CENTER Provides preventive primary health services when medically necessary and provided by or under the direction of a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, licensed clinical psychologist, or licensed clinical social worker. Facility is designated as an FQHC by Medicare if it is located in an area designated as a "shortage area", a geographic area designated by HHS as having either a shortage of personal health services or of primary medical care professionals. $5,725,094 4,670 $6,000,000 h55% 5,000 h36% SFY 2017 SFY 2017 $5,000,000 4,000 $5,725,094 of total 4,670 of $4,000,000 1% Medicaid expenditures 3,000 6% Medicaid recipients EXPENDITURES $3,000,000 RECIPIENTS 2,000 $2,000,000 SFY 2016 1,000 SFY 2016 $1,000,000 $3,689,548 3,438 $0 0 An FQHC differs from a Rural Health Clinic (RHC) based on several criteria related to location, shortage area, corporate structure, board of director requirements, and clinical staffing requirements.23 Table 27. Federally Qualified Health Center Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $1,550,274 $2,018,911 $2,698,283 $3,259,793 $3,689,548 $5,725,094 269 Recipients 2,722 3,612 4,034 5,987 3,438 4,670 72 Expenditures per Recipient $570 $559 $669 $544 $1,073 $1,226 115 The increase in expenditures for SFY 2017 is related to mass adjustments completed for FQHC dates of service between January 1, 2012 to December 31, 2016. This is a one-time increase in expenditures totaling $1,698,750. 23 Comparison of the Rural Health Clinic and Federally Qualified Health Center Programs, US Department of Health and Human Services Health Resources and Services Administration, Revised June 2006. http://www.ask.hrsa.gov/downloads/fqhc-rhccomparison.pdf 32 • Services


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    HOME HEALTH Services for individuals not admitted to the hospital or a nursing care facility. Must be intermittent, three or fewer visits per day for home health aide and/or skilled nursing, with each visit lasting no more than four hours. Services must be medically necessary, ordered by a physician, and documented in a signed/dated treatment plan to be reviewed and revised as medically necessary by the attending physician at least every 60 days. $10,000,000 $9,596,803 714 h1% i2% SFY 2017 $8,000,000 $9,596,803 750 of total SFY 2017 of $6,000,000 1.7% Medicaid 714 6% Medicaid EXPENDITURES 500 expenditures recipients $4,000,000 RECIPIENTS 250 $2,000,000 SFY 2016 SFY 2016 $9,467,835 730 $0 0 Home Health agencies must provide at least two of the following services to be a The following are NOT covered licensed provider in the state of Wyoming: Home Health services: • skilled nursing • homemaking • home health aide supervised by a qualified professional • respite care • physical therapy provided by a qualified and licensed physical therapist • Meals on Wheels or home- • speech therapy provided by a qualified therapist • occupational therapy provided by a qualified, registered, or certified therapist delivered meals • medical social services provided by a qualified and licensed Master of Social • services deemed Work (MSW) or a Bachelor of Social Work (BSW)-prepared person supervised inappropriate or not cost- by an MSW effective in home setting Table 28. Home Health Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $2,963,510 $2,897,016 $3,533,728 $4,618,885 $9,467,835 $9,596,803 224 Recipients 582 591 590 686 730 714 23 Expenditures per Recipient $5,092 $4,902 $5,989 $6,733 $12,970 $13,441 164 Medicaid implemented a prior authorization $8,000,000 requirement effective March 1, 2017, to $7,000,000 71% address the recent increase in expenditures. The effects of this policy change will not be $6,000,000 present in the current expenditure data due $5,000,000 to its implementation occurring late in the state fiscal year. $4,000,000 Table 29. Top 5 Home Health Providers $3,000,000 by Expenditures in SFY 2017 $2,000,000 % of Total Expenditures Home Health 7% 9% Expenditures $1,000,000 7% 3% 3% Provider 1 $6,790,781 71% $0 Provider 2 $711,488 7% Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Remaining Providers Provider 3 $690,723 7% Provider 4 $286,955 3% Figure 20. Top 5 Home Health Providers by Expenditures in SFY 2017 Provider 5 $249,667 3% Services • 33


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    HOSPICE An interdisciplinary approach to caring for the psychological, social, spiritual, and physical needs of dying individuals. Hospice care is covered if the individual elects it and a physician certifies that the individual is terminally ill. Covered services include routine and continuous home care, inpatient respite care, and general inpatient care. Inpatient services are provided during critical periods for individuals who need a high level of care. $1,316,838 224 h30% h14% $1,500,000 250 of total of $1,250,000 SFY 2017 0.2% Medicaid expenditures 200 SFY 2017 224 0.3% Medicaid recipients $1,000,000 $1,316,838 150 EXPENDITURES $750,000 RECIPIENTS 100 $500,000 SFY 2016 50 SFY 2016 $250,000 $1,014,959 197 $0 0 Table 30. Hospice Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $983,026 $1,082,188 $1,468,295 $1,157,101 $1,014,959 $1,316,838 34 Recipients 135 179 251 179 197 224 66 Expenditures per Recipient $7,282 $6,046 $5,850 $6,464 $5,152 $5,879 -19 34 • Services


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    HOSPITAL Inpatient and Outpatient hospital services $98,467,703 39,746 $125,000,000 i9% i3% $100,000,000 of total of SFY 2017 $98,467,703 18% Medicaid expenditures 40,000 52% Medicaid recipients SFY 2017 $75,000,000 39,746 72% EXPENDITURES $50,000,000 20,000 of Hospital RECIPIENTS SFY 2016 $107,692,150 Expenditures for $25,000,000 Inpatient services SFY 2016 40,800 $0 0 QUALIFIED RATE ADJUSTMENT The Qualified Rate Adjustment (QRA) is a supplement for qualified hospital providers. Qualifying hospitals provided state share of the payment, and Medicaid distributes corresponding Federal matching funds, along with the state share, to the participating hospitals. QRA payments are calculated using the previous SFY paid claims data. Table 31. Total Hospital Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $105,798,987 $108,839,452 $101,931,277 $104,523,947 $107,692,150 $98,467,703 -7 Recipients 44,107 42,666 40,033 42,464 40,800 39,746 -10 Expenditures per Recipient $2,399 $2,551 $2,546 $2,461 $2,640 $2,477 3 QRA (Federal Share) $6,833,447 $8,329,770 $8,604,610 $9,441,087 $12,607,068 $11,202,759 64 Total Expenditures w/ QRA $112,632,434 $117,169,222 $110,535,887 $113,965,034 $120,299,218 $109,670,462 -3 $120,000,000 Inpatient Outpatient $100,000,000 $80,000,000 $60,000,000 $40,000,000 73% 72% 73% 72% 70% 72% $20,000,000 $0 SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Figure 21. Hospital Inpatient-Outpatient Breakdown History by Expenditures Services • 35


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    $0 $20,000,000 $40,000,000 $60,000,000 $80,000,000 INPATIENT SERVICES Medicaid covers inpatient hospital services with the exception of alcohol and i10% SFY 2016 $78,575,068 SFY 2017 $71,022,272 chemical rehabilitation services, cosmetic surgery, and experimental services. Surgical procedures must be medically 0 2,000 4,000 6,000 8,000 10,000 necessary, and may not be covered if there is a non-surgical alternative or if a h6% SFY 2017 SFY 2016 provider performs the surgery only for the 9,570 10,142 convenience of the individual. Table 32. Inpatient Hospital Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $77,130,425 $78,462,603 $72,932,440 $73,407,132 $78,575,068 $71,022,272 -8 Recipients 10,890 10,970 10,293 10,599 9,570 10,142 -7 Expenditures per Recipient $7,083 $7,152 $7,086 $6,926 $8,211 $7,003 -1 QRA (Federal Share) $2,001,293 $2,248,251 $2,599,625 $2,667,482 $3,143,380 $2,200,706 10 Total Expenditures w/ QRA $79,131,718 $80,710,854 $75,532,065 $76,074,614 $81,718,448 $73,222,978 -7 Inpatient services reimbursement is determined by the Level of Care (LOC) classification assigned to each discharge based on the diagnosis, procedure, or revenue codes reported on the inpatient claim. 0% Kidney Transplant Kidney Transplant 7% 100% 0% Bone Transplant Bone Transplant 0% 90% 9% 1% NICU Rehab w/o Vent Rehab w/o Vent 9% 80% 11% 5% Psychiatric -7% Surgery Psychiatric NICU 12% 70% 12% Newborn Nursery Surgery -22% 60% Newborn Nursery 4% 18% 50% Routine Routine Discharge 0% Discharge Maternity -2% 40% ICU-CCU-Burn -23% 19% 30% Maternity -50% -25% 0% 25% 50% Figure 23. Change in Hospital Inpatient Expenditures 20% by Level of Care 21% 10% Eligible hospitals who serve a disproportionate number ICU-CCU-Burn of low-income individuals also receive Disproportionate Share Hospital (DSH) payments as required by Federal 0% law. These payments are capped according to state-specific SFY 2017 allotments. DSH payments are approximately $250K Figure 22. Percent of Hospital Inpatient Expenditures per year for all Wyoming hospitals due to Wyoming's low by Level of Care historical allottment from this Federal program. 36 • Services


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    $0 $10,000,000 $20,000,000 $30,000,000 OUTPATIENT SERVICES Medicaid covers outpatient hospital services, including emergency room, i6% SFY 2016 $28,975,050 SFY 2017 $27,373,462 surgery, laboratory, radiology, and other testing services. For individuals over age 21, visits to hospital outpatient 0 10,000 20,000 30,000 40,000 departments are limited to a maximum of 12 per calendar year. There are no limits i4% SFY 2017 SFY 2016 for Medicare crossovers, children under 38,664 37,282 age 21, or for visits for family planning, Health Check services, and emergency room. Table 33. Outpatient Hospital Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $28,657,373 $30,189,391 $28,703,147 $31,056,066 $28,975,050 $27,373,462 -4 Recipients 41,772 40,147 37,618 40,150 38,664 37,282 -11 Expenditures per Recipient $686 $752 $763 $774 $749 $734 7 QRA (Federal Share) $4,832,154 $6,081,517 $6,004,985 $6,773,605 $9,463,689 $9,002,053 86 Total Expenditures w/ QRA $33,489,527 $36,270,908 $34,708,132 $37,829,671 $38,438,739 $36,375,515 9 For each unit of service, reimbursement equals the APC APPLIES TO25: scaled relative weight for the Ambulatory Payment • Significant outpatient procedures Classification (APC), multiplied by a conversion • Ancillary services factor.24 When multiple units of service and different • Drugs • Select laboratory services services are provided, reimbursements are subject to • Radiology discounting and unit limitations. This is designed to • Select DME, Prosthetics/Orthotics reimburse hospitals based on the resources used to • Select Vaccines/Immunization not reimbursed provide services. Medicaid uses 3 conversion factors under Medicaid's physician fee schedule by hospital type: General Acute, Critical Access, and Children's Hospitals. 24 The scaled relative weight for an APC measures the resource requirements of the service and is based on the median cost (Medicare) of services in that APC. The conversion factor translates the scaled relative weights into dollar payment rates. 25 Some services from the APC methodology are reimbursed on separate fee schedules, as follows: select DME are covered under DME fee schedule; select vaccines/immunizations, select radiology and mammography screening, diagnostic mammographies and therapies are covered under the Physician fee schedule; laboratory services are reimbursed on the laboratory fee schedule; and corneal tissue, dental, and bone marrow transplants, and new medical devices covered under Medicare's transitional pass-through payments are reimbursed a percent of charges Services • 37


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    $0 $5,000,000 $10,000,000 EMERGENCY ROOM UTILIZATION The methodology used to identify emergency room utilization has been i2% SFY 2016 $13,112,661 SFY 2017 $12,904,782 updated in SFY 2017. This data excludes those visits that result in an inpatient 0 5,000 10,000 15,000 20,000 admission for both visit count and expenditures. Total ER expenditures include the total amount paid on claims with a line indicating treatment in the i4% SFY 2016 20,213 SFY 2017 19,424 ER. This change was made to include the cost of laboratory, radiology, and other 0 10,000 20,000 30,000 40,000 tests that may not be performed in the ER setting, but are still associated with the ER visit. i3% SFY 2016 39,048 SFY 2017 37,912 Table 34. Emergency Room Utilization Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $12,739,465 $12,896,119 $12,626,625 $14,135,281 $13,112,661 $12,904,782 1 Recipients 23,503 21,957 20,330 21,541 20,213 19,424 -17 Expenditures per Recipient $542 $587 $621 $656 $649 $664 23 Emergency Room Visits 45,950 41,788 38,687 42,759 39,048 37,912 -17 % of Total Medicaid 2.5% 2.5% 2.4% 2.7% 2.4% 2.3% Expenditures 100% As shown to the left, 44% of emergency Other, 1% room expenditures were spent on Children. ABD ID/DD/ABI, 90% Pregnant Women, 6% 2% The 1% allotted to "Other" includes the ABD EID, Non-Citizens with Medical 80% ABD Long-Term Emergencies, Special Groups, and ABD SSI, 17% Care, 3% Institution eligibility categories. 70% The chart below shows the average annual growth rate for each eligibility category's 60% Adults, 27% emergency room expenditures from SFY 2012 to SFY 2017. 50% -30%-25%-20%-15%-10% -5% 0% 5% 10% 15% 20% 40% ABD EID 14% ABD ID/DD/ABI 5% 30% ABD Institution -22% ABD Long-Term Care 7% Children, 44% ABD SSI 2% 20% Adults 6% Children -3% 10% Non-Citizens with Medical Emergencies -6% Pregnant Women -4% 0% Special Groups -17% Figure 24. Emergency Room Expenditures by Figure 25. Average Yearly Growth Rate of Emergency Room Eligibility Category Expenditures by Eligibility Category 38 • Services


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    Table 35. Emergency Room Utilization by Eligibility Category % Change % Change % Change Eligibility Category Expenditures26 from SFY Recipients from SFY ER Visits from SFY 2016 2016 2016 ABD EID $104,275 9 63 -3 142 13 ABD ID/DD/ABI $217,124 4 341 11 659 11 ABD Institution $5,744 -62 8 -50 13 -46 ABD LTC $385,206 15 250 8 697 11 ABD SSI $2,153,428 2 1,799 4 5,235 3 Adults $3,435,300 -6 3,738 -2 8,701 -5 Children $5,686,545 -2 12,316 -5 20,154 -5 Non-Citizens with Medical Emergencies $39,500 -21 40 -26 63 -9 Pregnant Women $838,149 3 1201 -8 2,259 5 Special Groups $32,297 -17 36 24 60 -3 Total $12,904,782 -2 19,424 -4 37,912 -3 Change in Expenditures Change in Recipients Change in Visits 20% 13% 15% 9% 11% 11% 8% 11% 10% 4% 2% 4% 3% 0% -10% -3% -20% -30% -40% -50% -46% -60% -50% -70% -62% ABD EID ABD ID/DD/ABI ABD Institution ABD Long-Term Care ABD SSI 30% 24% 20% 10% 5% 3% 0% -2% -2% -3% -10% -6% -5% -5% -5% -9% -8% -20% -17% -21% -30% -26% Adults Children Non-Citizens with Medical Pregnant Women Special Groups Emergencies Figure 26. Change in Emergency Room Utilization from SFY 2016 to SFY 2017 by Eligibility Category 26 Screenings and Gross Adjustments are excluded from this table; as such, summing expenditures across the eligibility categories will not match the total shown. Services • 39


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    One-quarter (26%) of Medicaid recipients used emergency room services in SFY 2017. Adults had the greatest portion of recipients receiving emergency room services, with 36%, while ABD Long-Term Care had the fewest percentage, with 5%. Emergency room services accounted for 2.3% of total Medicaid expenditures in SFY 2017, with the Adult population having the greatest percentage (8.5%) of their total expenditures going toward emergency room services. Emergency room expenditures for Non-citizens with Medical Emergencies only account for 3.8% of their total expenditures due to emergency room utilization excluding any Emergency Room visit that results in an inpatient admission. 40% % of Recipients Using ER 35% % of Expenditures Paid for ER 30% 25% 20% 15% 10% 5% 0% ABD EID ABD ABD ABD Long- ABD SSI Adults Children Non-Citizens Pregnant Special ID/DD/ABI Institution Term Care with Medical Women Groups Emergencies Figure 27. Emergency Room Utilization vs Total Medicaid by Eligibility Category Table 36. Emergency Room Utilization vs Total Medicaid by Eligibility Category Total ER % Using ER ER Total Medicaid % Paid for ER Eligibility Category Medicaid Recipients Services Expenditures Expenditures27 Services Recipients ABD EID 63 514 12% $104,275 $4,444,205 2.3% ABD ID/DD/ABI 341 2,661 13% $217,124 $144,912,157 0.1% ABD Institution 8 109 7% $5,744 $2,806,510 0.2% ABD LTC 250 5,064 5% $385,206 $133,737,121 0.3% ABD SSI 1,799 6,355 28% $2,153,428 $54,964,847 3.9% Adults 3,738 10,273 36% $3,435,300 $40,492,988 8.5% Children 12,316 46,268 27% $5,686,545 $140,647,477 4.0% Non-Citizens with Medical Emergencies 40 252 16% $39,500 $1,040,454 3.8% Pregnant Women 1,201 5,296 23% $838,149 $26,246,328 3.2% Special Groups 36 132 27% $32,297 $1,515,573 2.1% Total 19,424 75,921 26% $12,897,569 $555,419,725 2.3% 40 • Services


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    INTERMEDIATE CARE FACILITY - INTELLECTUALLY DISABLED Services covered only in a residential facility licensed and certified by the state survey agency as an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-ID). The Wyoming Life Resource Center is the sole facility in the state. This service is unique to Medicaid and is not commonly covered by other payers. $19,204,867 66 h6% i6% $20,000,000 75 SFY 2017 $15,000,000 $19,204,867 of total SFY 2017 of 3.5% Medicaid expenditures 50 66 0.1% Medicaid recipients $10,000,000 EXPENDITURES RECIPIENTS 25 $5,000,000 SFY 2016 SFY 2016 $18,193,221 70 $0 0 Table 37. Intermediate Care Facility - Intellectually Disabled Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $10,065,657 $17,942,326 $19,152,530 $18,091,427 $18,193,221 $19,204,867 91 Recipients 84 81 79 75 70 66 -21 Expenditures per Recipient $119,829 $221,510 $242,437 $241,219 $259,903 $290,983 143 LABORATORY Medicaid covers professional and technical laboratory services ordered by a practitioner that are directly related to the diagnosis and treatment of the individual as specified in the treatment plan developed by the ordering practitioner. $1,750,000 $844,218 10,000 8,015 i45% i16% $1,500,000 $1,250,000 7,500 SFY 2017 $1,000,000 of total 8,015 of EXPENDITURES $750,000 SFY 2017 0.2% Medicaid 5,000 11% Medicaid RECIPIENTS $844,218 expenditures recipients $500,000 2,500 SFY 2016 SFY 2016 $250,000 9,540 $1,536,310 $0 0 Table 38. Laboratory Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $1,100,774 $1,149,473 $1,284,678 $1,516,042 $1,536,310 $844,218 -45 Recipients 9,415 9,724 9,490 8,830 9,540 8,015 -16 Expenditures per $117 $118 $135 $172 $161 $105 -35 Recipient Services • 41


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    NURSING FACILITY Medicaid covers nursing facility services for individuals who are no longer able to live in the community. The nursing facility is an institution, or a distinct part of an institution, which is not primarily for the care and treatment of mental diseases, and provides skilled nursing care and related services to residents who require medical or nursing care, rehabilitation services for injured, disabled or sick individuals, and health-related care and services to individuals who, because of their mental or physical condition, require care and services (above the level of room and board) which is available to them only through institutional facilities. $90,000,000 $87,001,112 2,552 SFY 2017 $87,001,112 h6% 3,000 h7% $60,000,000 of total of SFY 2017 16% Medicaid expenditures 2,000 2,552 3% Medicaid recipients EXPENDITURES RECIPIENTS $30,000,000 1,000 SFY 2016 SFY 2016 $82,445,811 2,388 $0 0 NURSING FACILITY PAYMENT DESCRIPTIONS Per Diem Rate Provider Assessment and Extraordinary Care Per Diem Rates Based on facility-specific cost reports Upper Payment Limit (UPL) May not exceed maximum rate established Paid for services provided to a resident with by Medicaid extraordinary needs Supplemental payment for qualified Includes: nursing facilities Limited reserve bed days Medicaid determines per case rates for Routine services (room, dietary, laundry, Based on calculations from most extraordinary care based on relevant cost and a nursing, minor medical surgical supplies, recent cost reports & comparisons review of medical records. non-legend pharmaceutical items, use of to what would have been paid for equipment & facilities) Medicaid services under Medicare's payment principles Enhanced Adult Psychiatric Excludes: Reimbursement physician visits, hospitalizations, laboratory, x-rays, and prescription drugs Assessment collected on all non- which are reimbursed separately. Medicare days & UPL payment paid Provided to encourage nursing facilities to accept on Medicaid days once corresponding adults who require individualized psychiatric care federal matching dollars are obtained. Figure 28. Nursing Facility Payment Descriptions Table 39. Nursing Facility Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures $73,805,803 $73,593,462 $72,866,933 $70,354,260 $82,445,811 $87,001,112 18 Recipients 2,410 2,445 2,384 2,342 2,388 2,552 6 Expenditures per Recipient $30,625 $30,100 $30,565 $30,040 $34,525 $34,091 11 Provider Assessment (Federal $12,748,232 $14,299,645 $15,537,040 $15,219,087 $14,689,893 $15,275,937 20 Share) Total Expenditures with $86,554,035 $87,893,107 $88,403,973 $85,573,347 $97,135,704 $102,277,049 18 Provider Assessment 42 • Services


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    PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Available in Laramie County to qualified individuals ages 55 and older as an alternative to nursing home care. Each participant has a plan of care developed by a team of healthcare professionals to improve and maintain the participant’s overall health. The participant works with the team to develop and update their plan of care. $4,000,000 $3,520,283 150 2,552 SFY 2017 h20% 125 SFY 2017 h7% $3,000,000 $3,520,283 141 of total 100 of 0.6% Medicaid 0.2% Medicaid EXPENDITURES $2,000,000 expenditures 75 recipients RECIPIENTS 50 $1,000,000 SFY 2016 SFY 2016 25 117 $2,934,877 $0 0 Services provided include: primary care, specialty medical care, dental, social work counseling, meals, nutritional counseling, laboratory, radiology, prescription drug, hospital, emergency, nursing home, home care, adult day care, personal care, physical therapy, occupational therapy, recreational therapy, and transportation. Table 40. Program of All-Inclusive Care for the Elderly Services Summary 4 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Expenditures - $168,398 $1,288,934 $2,242,570 $2,934,877 $3,520,283 1,990 Recipients - 22 63 95 117 141 541 Expenditures per Recipient - $7,654 $20,459 $23,606 $25,084 $24,967 226 PHYSICIANS AND OTHER PRACTITIONERS Services provided by physicians and other practitioners, with the following limits: • Hospital outpatient departments, physician offices, and optometrist offices - maximum of 12 visits per calendar year for individuals over age 21 • Physical, occupational, and speech therapy - maximum of 20 visits each per calendar year for individuals over age 21 There is no limit for Medicare crossovers or children under age 21; also no limit for family planning visits, Health Check services, or emergency services. $60,013,763 63,894 $60,000,000 h3% h4% SFY 2017 of total 60,000 SFY 2017 of $50,000,000 $60,013,763 11% Medicaid expenditures 50,000 63,894 84% Medicaid recipients $40,000,000 40,000 $30,000,000 37% 71% EXPENDITURES 30,000 of expenditures paid of recipients using RECIPIENTS $20,000,000 to family health, 20,000 this service visited a $10,000,000 SFY 2016 family practice, or SFY 2016 family health, family 10,000 $58,278,406 general practice 61,460 practice, or general $0 physicians 0 practice physician Services • 43


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    Table 41. Physician and Other Practitioner Services Summary 5 Year SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 % Change Total Physician and Other Practitioner Services Expenditures $62,845,816 $62,856,989 $62,372,535 $61,249,367 $58,278,406 $60,013,763 -5 Recipients 63,695 61,515 65,284 62,816 61,460 63,894 0 Expenditures per Recipient $987 $1,022 $955 $975 $948 $939 -5 Physician Only Services Expenditures $57,483,815 $57,459,450 $56,694,139 $54,142,991 $50,015,210 $51,857,906 -10 Recipients 63,158 60,830 64,720 62,108 60,697 63,184 0 Expenditures per Recipient $910 $945 $876 $872 $824 $821 -10 Other Practitioner Services Expenditures $5,362,001 $5,397,540 $5,678,397 $7,106,377 $8,263,196 $8,155,858 52 Recipients 7,713 8,034 7,778 9,208 9,094 8,708 13 Expenditures per Recipient $695 $672 $730 $772 $909 $937 35 Physician Other Practitioner The majority of Medicaid 0% 20% 40% 60% 80% 100% expenditures for these services is paid to ABD EID 95% physicians; however, Figure ABD ID/DD/ABI 35% 29 to the right shows that the ABD ID/DD/ABI ABD Institution 99% eligibility category spends a greater percentage for ABD Long-Term Care 91% other practitioners than for physicians. ABD SSI 87% Adults 92% Other Practitioners Physical Therapists Children 89% Occupational Therapists Speech-Language Medicare Savings Programs 91% Pathologists Podiatrists Non-Citizens with Medical Emergencies 100% Nurse Practitioners Nurse Midwives Pregnant Women 98% Nurse Anesthetists Audiologists Special Groups 97% Figure 29. Physician and Other Practitioner Expenditure Breakdown by Eligibility Category Relative Value Scale Used to reimburse medical services provided by physicians, physician assistants, physical and occupational therapists, ophthalmologists, and nurse practitioners. Based on estimates of the costs Resource-based of resources required to provide physician services using a relative value unit (RVU) and conversion factor. RVU x Conversion Factor = fee schedule rate RVU reflects the resources used by a physician to deliver a service, compared to resources used for other physicians' services, taking into consideration the time and intensity of the physician's effort, and the physician's practice and malpractice expenses. Services provided by anesthesiologists are reimbursed using RVUs developed and published by the American Society of Anesthesiologists. 44 • Services

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