WYOMING DEPARTMENT OF HEALTH

[Pages:150]WYOMING DEPARTMENT OF HEALTH

WYOMING MEDICAID

SFY 2020

ANNUAL REPORT

MARK GORDON Governor

MICHAEL A. CEBALLOS Director

TERI GREEN State Medicaid Agent

CONTENTS

SFY 2020 At A Glance.................................................................................................................................................................................1 Wyoming Medicaid Background...........................................................................................................................................................3 Highlights and Initiatives.........................................................................................................................................................................8 Enrollment.................................................................................................................................................................................................. 10 Expenditures.............................................................................................................................................................................................. 12 Recipients.................................................................................................................................................................................................... 13 Eligibility Categories............................................................................................................................................................................... 14 Services........................................................................................................................................................................................................ 17

Ambulance.......................................................................................................................................................................................... 23 Ambulatory Surgery Center.......................................................................................................................................................... 24 Behavioral Health............................................................................................................................................................................. 24 Care Management Entity............................................................................................................................................................... 26 Clinic / Center................................................................................................................................................................................... 26 Dental................................................................................................................................................................................................... 27 Durable Medical Equipment, Prosthetics & Supplies.......................................................................................................... 28 End Stage Renal Disease................................................................................................................................................................ 29 Federally Qualified Health Center.............................................................................................................................................. 30 Home Health...................................................................................................................................................................................... 31 Hospice................................................................................................................................................................................................ 32 Hospital................................................................................................................................................................................................ 33

Inpatient Services.............................................................................................................................................................................. 34 Outpatient Services........................................................................................................................................................................... 34 Emergency Room Services.............................................................................................................................................................. 35 Intermediate Care Facility for Individuals with Intellectual Disabilities...................................................................... 37 Laboratory.......................................................................................................................................................................................... 38 Nursing Facility................................................................................................................................................................................. 39 Program for All Inclusive Care for the Elderly (PACE)........................................................................................................ 40 Physician & Other Practitioner................................................................................................................................................... 41 Prescription Drugs........................................................................................................................................................................... 42 Psychiatric Residential Treatment Facility.............................................................................................................................. 43 Public Health or Welfare................................................................................................................................................................ 44 Public Health, Federal..................................................................................................................................................................... 44 Rural Health Clinic........................................................................................................................................................................... 45 Vision.................................................................................................................................................................................................... 46 Waivers................................................................................................................................................................................................. 47 Community Choices Waiver.......................................................................................................................................................... 50 Comprehensive Waiver.................................................................................................................................................................... 51 Supports Waiver................................................................................................................................................................................. 52 Pregnant By Choice Waiver............................................................................................................................................................ 53 Subprograms and Special Populations............................................................................................................................................. 55 Medicaid/Medicare Dual Enrolled............................................................................................................................................. 60 Foster Care.......................................................................................................................................................................................... 64 Appendix A: Supplemental Tables...................................................................................................................................................... 66 Appendix B: Reimbursement Methodology.................................................................................................................................... 80 Appendix C: Eligibility Requirements and Benefits...................................................................................................................... 90 Appendix D: Glossary and Acronyms................................................................................................................................................ 94 Appendix E: Data Methodology......................................................................................................................................................... 100

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LIST OF FIGURES

Figure 1. Wyoming Department of Health Organization Chart..................................................................................................3 Figure 2. Health Care Financing Expenditure History....................................................................................................................5 Figure 3. Health Care Financing Funding History............................................................................................................................5 Figure 4. Enrollment History: Unique and Monthly Average.................................................................................................... 10 Figure 5. Monthly Medicaid Enrollment by State Fiscal Year.................................................................................................... 10 Figure 6. Wyoming County Map by Medicaid Enrollment......................................................................................................... 11 Figure 7. Expenditure History.............................................................................................................................................................. 12 Figure 8. Top Services Expenditures as % of Total Medicaid Expenditures SFY 2020 vs SFY 2019.................................. 12 Figure 9. Recipient History.................................................................................................................................................................... 13 Figure 10. Recipient Utilization versus Expenditure Breakdown by Service Type............................................................ 13 Figure 11. Enrolled Members versus Expenditures by Eligibility Category - SFY 2020.................................................... 14 Figure 12. SFY 2020 Top Services by Expenditures....................................................................................................................... 19 Figure 13. One-Year Change in Expenditures for Top Services................................................................................................. 19 Figure 14. Percent of Unduplicated Recipients by Service......................................................................................................... 19 Figure 15. Top Five Behavioral Health Diagnosis Codes by Expenditures for all Provider Types (excluding Dementia and Alzheimers)............................................................................................................................................. 25 Figure 16. Hospital Inpatient-Outpatient Breakdown History by Expenditures................................................................ 33 Figure 17. Emergency Room Utilization vs Total Medicaid by Eligibility Category.......................................................... 36 Figure 18. Expenditures for Court Ordered Psychiatric Residential Treatment Facility Services with Incorrect Language or No Medical Necessity..................................................................................................................................................... 43 Figure 19. Waiver vs Non-Waiver Expenditures History............................................................................................................. 48 Figure 20. Total Expenditure History for Transition from Adult and Child ID/DD Waivers to Comprehensive and Supports Waivers............................................................................................................................................................................. 49 Figure 21. Non-Waiver Services Expenditure History for Transition from Adult and Child ID/DD Waivers to Comprehensive and Supports Waivers............................................................................................................................................. 49 Figure 22. SFY 2020 Waiver-Only versus Non-Waiver Services by Waiver............................................................................ 50 Figure 23. SFY 2020 Total Waiver Expenditure Breakdown by Waiver.................................................................................. 50 Figure 24. Wyoming Health Information Exchange and Medicaid......................................................................................... 56 Figure 25. Dual Enrolled Claims Coverage Process...................................................................................................................... 60 Figure 26. Dual Enrolled as Percent of Total Medicaid in SFY 2020........................................................................................ 61 Figure 27. History of Dual Enrollment and Expenditures as Percent of Total Medicaid................................................. 61 Figure 28. History of Crossover Expenditures as Percent of Total Dual Expenditures..................................................... 61 Figure 29. Crossover Expenditures as Percent of Dual Expenditures by Service Area for SFY 2020........................... 61 Figure 30. Percent of Total Unduplicated Dual Recipients by Service................................................................................... 63 Figure 31. Dual Expenditures as Percent of Total Medicaid Expenditures by Service..................................................... 63 Figure 32. Percent of Foster Care Expenditures by Service - Medicaid versus State-Only.............................................. 65

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LIST OF TABLES

Table 1. Division of Health Care Financing Expenditures for SFY 2020...................................................................................4 Table 2. Wyoming Medicaid Advisory Groups and Committees................................................................................................6 Table 3. Medicaid Cost Avoidance and Recoveries - SFY 2020....................................................................................................6 Table 4. Employment and Mean Wages by Occupation.................................................................................................................7 Table 5. Change in Medicaid Enrollment......................................................................................................................................... 10 Table 6. Medicaid Enrollment by County......................................................................................................................................... 11 Table 7. Expenditure History by Service Type ............................................................................................................................... 12 Table 8. Recipient History by Service Type ..................................................................................................................................... 13 Table 9. Eligibility Category Summary.............................................................................................................................................. 15 Table 10. Enrollment History by Eligibility Category................................................................................................................... 15 Table 11. Expenditures History by Eligibility Category............................................................................................................... 16 Table 12. Unique Recipient History by Eligibility Category....................................................................................................... 16 Table 13. Covered Services.................................................................................................................................................................... 17 Table 14. Service Utilization Summary............................................................................................................................................. 18 Table 15. Expenditure History by Service......................................................................................................................................... 20 Table 16. Expenditure History by Other18 Service......................................................................................................................... 21 Table 17. Recipient Count19 History by Service.............................................................................................................................. 22 Table 18. Ambulance Services Summary......................................................................................................................................... 23 Table 19. Ambulatory Surgery Center Services Summary......................................................................................................... 24 Table 20. Behavioral Health Services Summary............................................................................................................................. 25 Table 21. Top Five Behavioral Health Diagnosis Codes by Expenditures for all Provider Types.................................. 25 Table 22. Care Management Entity Services Summary............................................................................................................... 26 Table 23. Clinic/Center Services Summary..................................................................................................................................... 27 Table 24. Dental Services Summary................................................................................................................................................... 27 Table 25. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Services Summary............................... 28 Table 26. End Stage Renal Disease Services Summary................................................................................................................ 29 Table 27. Federally Qualified Health Center Services Summary.............................................................................................. 30 Table 28. Home Health Services Summary...................................................................................................................................... 31 Table 29. Hospice Services Summary................................................................................................................................................ 32 Table 30. Total Hospital Services Summary.................................................................................................................................... 33 Table 31. Inpatient Hospital Services Summary............................................................................................................................ 34 Table 32. Outpatient Hospital Services Summary........................................................................................................................ 34 Table 33. Emergency Room Utilization Summary........................................................................................................................ 35 Table 34. Emergency Room Utilization by Eligibility Category................................................................................................ 35 Table 35. Emergency Room Utilization vs Total Medicaid by Eligibility Category............................................................ 36 Table 36. Intermediate Care Facility for Individuals with Intellectual Disabilities Services Summary..................... 37 Table 37. Laboratory Services Summary.......................................................................................................................................... 38 Table 38. Nursing Facility Services Summary................................................................................................................................. 39 Table 39. Program for All-Inclusive Care for the Elderly Services Summary....................................................................... 40 Table 40. Physician and Other Practitioner Services Summary............................................................................................... 41 Table 41. Prescription Drug Services Summary ........................................................................................................................... 42 Table 42. Pharmacy Cost Avoidance - SFY 2020............................................................................................................................ 42 Table 43. Prescription Drug Rebates History.................................................................................................................................. 42 Table 44. Psychiatric Residential Treatment Facility Services Summary ............................................................................ 43 Table 45. Public Health or Welfare Services Summary................................................................................................................ 44 Table 46. Rural Health Clinic Services Summary.......................................................................................................................... 45 Table 47. Public Health, Federal Services Summary.................................................................................................................... 45 Table 48. Vision Services Summary.................................................................................................................................................... 46 Table 49. Home and Community Based Services Waiver Summary....................................................................................... 48 Table 50. Home and Community Based Services Waiver Expenditures History by Waiver........................................... 49 Table 51. Community Choices Waiver Summary.......................................................................................................................... 50 Table 52. Comprehensive Waiver Summary.................................................................................................................................... 51

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Table 53. Supports Waiver Summary................................................................................................................................................. 52 Table 54. Pregnant by Choice Waiver Summary............................................................................................................................ 53 Table 55. Administrative Transportation Summary..................................................................................................................... 57 Table 56. Patient Centered Medical Home Summary.................................................................................................................. 58 Table 57. Project Out Summary........................................................................................................................................................... 59 Table 58. Medicaid/Medicare Dual Enrollment Summary........................................................................................................ 60 Table 59. Dual Enrolled Member Service Utilization Summary............................................................................................... 62 Table 60. Foster Care Summary........................................................................................................................................................... 64 Table 61. Foster Care Summary by Services - Medicaid versus State-Only.......................................................................... 65 Table 62. Behavioral Health Services by Provider Type.............................................................................................................. 66 Table 63. Waiver Services by Waiver.................................................................................................................................................. 67 Table 64. Wyoming Medicaid Births.................................................................................................................................................. 67 Table 65. County Summary................................................................................................................................................................... 68 Table 66. Provider Summary by Taxonomy - SFY 2020............................................................................................................... 69 Table 67. Top 20 Provider Taxonomies by Expenditures............................................................................................................ 72 Table 68. Provider Count History by Taxonomy............................................................................................................................ 72 Table 69. Provider Expenditures History by Taxonomy.............................................................................................................. 76 Table 70. Reimbursement Methodology and History by Service Area................................................................................... 80 Table 71. Income Limits by Eligibility Category............................................................................................................................ 90 Table 72. Monthly Income Standard Values by Family Size....................................................................................................... 90 Table 73. Eligibility Requirements...................................................................................................................................................... 91 Table 74. Acronyms.................................................................................................................................................................................. 98 Table 75. Medicaid Chart A Eligibility Program Codes............................................................................................................. 101 Table 76. Medicaid Chart B Eligibility Program Codes.............................................................................................................. 105 Table 77. Data Parameters by Service Area................................................................................................................................... 106 Table 78. Data Parameters for Subprogram and Special Populations................................................................................. 111

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SFY 2020 AT A GLANCE

EXPENDITURES

$544 million

paid to 3,445 providers with over 15,500 providers accurately enrolled at any point during the SFY

$554.6

$556.3

$567.5

$527.5

$554.0 $543.8

ENROLLMENT

75,360

members enrolled at any point during the SFY with 55,874 enrolled each month on average

91,062 74,628

88,775 66,696

84,785 63,247

80,406 60,263

76,964 57,330

75,360 55,874

SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020

13% Wyoming residents enrolled

in Medicaid

62%

of members are children under

age 21

SFY2015 SFY2016 SFY2017 SFY2018 SFY2019 SFY2020

45%

9.3

Dental - 2% Long-Term Care - 48%

of members reside in Laramie,

Natrona, and Fremont counties

months of average enrollment per member

Medical - 50%

Other - ................
................

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