How to Find Medicaid Rates for Assisted Living

Transcript

00:00:01
Hey friend, it is Brandon Gustafson with Assisted Living Investing. Excited to have you here with me on the channel. I hope it begins like you launch their assisted living business in the next 12 months. In our video today, we're going to be talking about how to find Medicaid rates for assisted living. I talked to a lot of you that you're interested in Medicaid, and I've done a lot of videos on Medicaid here on the channel.

00:00:22
But I get questions all the time, like, how do I know what this is going to look like? How do I find this? Like, Medicaid doesn't fit in my state. They don't do it there. So I wanted to really dive into that today to help clear up some of the questions and some of the issues that happen and the confusion that exists around Medicaid. So you know exactly what to expect as you're trying to go through this process.

00:00:47
I truly believe that Medicaid is one of the best ways for you to be successful in assisted living. It opens up the doors to serving a bigger population and working with a bigger group of people. And that is only going to help you out as you're trying to keep your beds full and keep the cash flow going. So with that, I want to remind you to go and grab the free business plan checklist. We're going to have a link down here for you on the screen while I go throughout this. So make sure you go and grab that tool.

00:01:17
assistedlivinginvesting.net bp checklist um and sorry i've got something in my throat make sure you go grab that tool and um you know we're gonna start talking now about how to find those medicaid residents uh those medicaid rates not necessarily the residents but medicaid rates for your assisted living

00:01:36
business so you know as you're doing underwriting you can figure out exactly what that's going to look like for those of you who don't know me my name is brandon brandon gustafson i own and operate two assisted living facilities i've been doing that since 2020 i actually do it out of state i live in utah and i operate in colorado and in idaho i've secured over one and a half million dollars in sba funding and know that process i've actually done three sba loans uh really good at that have a master's in healthcare administration have been working in the industry for

00:02:04
uh, for over a decade, uh, just in the healthcare industry as a whole, uh, for over a decade. Um, and I would say 90% of my residents and my facilities are Medicaid residents. So this is something that I, that I teach people. Um, and it's something that I practice. So, uh, it's something that I really believe that you can be successful with it. If you are new here, type in newbie down below. And for those of you that are live, make sure you're typing in your questions. Cause we're going to have time for questions here at the end of the video.

00:02:31
Uh, and for those of you that can't catch it live for whatever reason, um, that's okay. Make sure you like the video, subscribe and ring the bell. So you get notified every time we put out this, we do these lives, we go live on Tuesday. Um, but then you also can put in your questions beforehand. And for those of you that are in ALI basics, um, make sure you're typing in your questions there inside of that community so that we can hit on those as we are moving forward. Um, and, and,

00:02:57
and doing things there within that community. If you want to check out ALI Basics, go to assistedlivinginvesting.net slash basics, and we'd love to have you inside of our community there. Now, let's talk about Medicaid, what it is. Last week, we actually went really deep into this, the differences, and I'm going to give you kind of a high-level overview of what Medicaid is for those of you who are new to this and new to the idea of Medicaid.

00:03:22
So Medicaid is a state-based healthcare program. It's administered by the state. It uses federal funding to this. So it provides funding, it receives federal funding, the state does, and they say, we're gonna use this money and we're gonna decide how we wanna use it. That funding is dedicated to providing care for qualified participants. There are several ways that an individual can qualify for Medicaid.

00:03:49
The biggest one is financial reasons. So you'll see that one most consistently. But as individuals age and get older, they'll often be able to qualify for being elderly or disabled in addition to the financial component. Usually if they are elderly, they're still going to have to qualify financially.

00:04:09
So they have to prove out that they don't have the funds available, that they don't have extra money coming in and those types of things. But elderly is a waiver, typically, that people can qualify for Medicaid with. It is available for assisted living. So typical, like Medicare is not. Medicare is different from Medicaid. Medicaid is a state-based program. Medicare is a federal. Medicare does not do assisted living. Medicaid does do assisted living.

00:04:38
It's a benefit that they will pay for. And the difference there is Medicare is for much more like inpatient stays or potentially outpatient stays as well. Parts A and B of Medicare, or there's part D, which is prescriptions. Your residents at your facility could be on Medicare. They probably are if they're an elderly care type of a facility.

00:05:02
but you as an assisted living facility owner will not be able to get reimbursed for anything as a medic as a provider you're not a medicare provider but you can be medicaid certified and and work through that process it's a little bit confusing i wish they would have used different uh different words for it because people think they're interchangeable they're not they're very very different um and it's hard for people to understand that medicaid is the one that you want to be looking at though um

00:05:31
And also the thing that I want to note, and we're going to get into this as we get into how to find these Medicaid rates for your states, is they could be called something different in your state. So oftentimes it's going to be under HCBS, which stands for Home and Community Based Services. That's pretty common in a lot of states, but not every state is going to call it that. Some states will call it Medicaid. Texas, it's called like the STAR Plus program.

00:05:57
California, it's Medi-Cal. So it really depends on what the state decides to call it. And that can make it really hard for you to find, you know, does my state actually have Medicaid? It does have Medicaid. I promise you it does.

00:06:12
It's just what is it called? That's where there can be differentiations there. And it can make it really confusing as you're trying to navigate all of this and get things started. So it can be called differently depending on the state that you're in. So that's a very quick overview of what Medicaid is and understanding.

00:06:32
Now, let's talk about what a fee schedule is. So a fee schedule and we're going to talk about this a little bit more as we go through the video. But a fee schedule is a list of rates. This is what's going to tell you how much you can get paid. So it's a list of specific prices or rates that a health care provider charges for their services.

00:06:52
fee schedules are very common in the health care insurance industry. So whether this is Medicare or Medicaid or commercial private insurance, like you have private health insurance through your employer, there will be a fee schedule that that insurance has negotiated with the provider. And they say, OK, you came in for a wellness checkup. You, the patient, don't have to pay for that as an insurance. We're going to pay the provider

00:07:21
$50, $100, whatever the rate is that's negotiated, that negotiated rate is on a fee schedule. So it just tells the insurance how much they have to pay out to a provider. So that's kind of how it works at its core. It details that fee schedule is going to detail the amount to be paid

00:07:42
for the different services and procedures and the different products. There's a lot that goes into this. There's coding, there's modifiers. These are all things that I'm not gonna get too deep into, because this is not a course on medical billing. But when you get into the world of Medicaid, you're gonna get familiar with these.

00:07:59
Now, what's nice is with assisted living and Medicaid, there's really only one code. And so it really simplifies things for you as a provider. You don't have to know all of the different codes and what each one says. And if it was for 60 minutes versus 30 minutes or anything like that, those that are watching me that have done medical billing, you're like, yeah, you're nodding your head. You're just like, yeah, it's ridiculous. For those of you that don't know it,

00:08:24
It's ridiculous. There's a lot that comes into it So I have a background in in medical billing and coding something that I did as a job professionally I don't know how long ago like 15 years ago probably So I got a lot of experience there and the different modifiers that you use and then I also have worked on Billing like claims billing the person that processes the claim so I got really familiar with a lot of those cold codes specifically around mental health as a lot of what I did previously and

00:08:54
So I'm very familiar with that world. You as a provider, you're going to have to get familiar with it a little bit, but I promise you it's not overwhelming. So that's what a fee schedule is. And you need to have that base understanding of what Medicaid is and what a fee schedule is so that you can then find the Medicaid rates for your facility, for your state, for what you're trying to do. So once you have that, it's going to really simplify what you're looking for.

00:09:24
So this is an example of what a fee schedule looks like. Now, when you're trying to go and find a fee schedule, this is what you want to be looking for. This is the one that is for the state of Colorado. So one of my facilities is in Colorado. This is what we look for when we are trying to find our our rates for assisted living. Yours may or may not look the exact same, but it's going to probably look pretty similar to here. So what you're going to see here is there's a waiver type where it says

00:09:53
elderly blind and disabled waiver so that's how a person is going to qualify so i have a resident who is on medicaid and they qualify for medicaid for being elderly blind and disabled then this is the rate that is going to be paid out for that person now if i have a a resident that is qualifying for it for a different reason there's going to be a separate fee schedule for that

00:10:17
For assisted living, it's pretty much the same. But if you are working with other types of residents or other types of care, then you may have different rates. It's really quite simple for assisted living, which is really, really beneficial. So you want to see...

00:10:33
Again, right here, home and community-based services. This is who is assigning those waivers out. Elderly, blind, and disabled, that's a specific waiver that a resident's going to be on. You have your rate effective dates. So these ones are effective as of May 1st. These ones are going into effect here in about a week. So they will put these out ahead of time.

00:10:51
you'll see this one right here it's actually only going to be effective for about a two month period that's because in the state of colorado at least they will revise rates every july 1st but as they get closer to the end of the year the last two or three months they will look at their budget

00:11:09
they'll oftentimes revise a rate up or down just a little bit usually it's up but they'll adjust it to use the funds that they have because the way that because this is federal government if they don't use those funds that they've received from the state from the fed then they will lose those funds and and they can't use them for something else and they are trying to match their budget so they will oftentimes look at what has happened historically here

00:11:35
Where are we trending? And then they'll adjust to kind of balance that out at the end of the year. And then you'll get a new fee schedule going into the next year. They typically will send out emails on these when you are a Medicaid provider. So you know what's going on, but you can go out and it's publicly available data.

00:11:55
I'll show you how to search for something like that. Something like this here in just a few minutes. Okay. So, and you can see right there, the issue date, this, this came into effect. They notified us on April 1st. Hey,

00:12:07
On May 1st, you're going to have an adjustment to your rate. Now, there may or may not be an adjustment. You can see in this instance, my rate effective date on January 1 of 2025, and my effective rate for May 1st, 2025, for me doing assisted living, is the exact same rate. So there's no change for me, but other services that are provided, there could be changes. So that's the difference here. Okay.

00:12:36
and then this is going to be your service type so right here this is your service description you're going to have alternative care facility that's what they call it for us for our type of facility in colorado and in colorado they have rates that are denver specific and then anywhere but denver so we're outside of denver we're in um we're in el paso county and colorado springs and so our rate is this one that's on the top

00:13:01
So I can see it's alternative care facility, ACF outside of Denver. This is my unit value. So I only get to build this code one time per day, but it's all encompassing. It's everything that happens during the day. And then this is my procedure codes. When I am billing my insurance, when I bill Medicaid, I'm going to use this code. I'm going to use this modifier. And if I don't do those things, I will not get paid. And so that's,

00:13:25
This fee schedule tells you exactly what you need to do. Here's the service. It's alternative care facility. Your code is T2031 and your modifier is U1. This is Colorado specific. So if you're looking in Texas or New York or California, it's going to be a different code because these are set by the different states.

00:13:44
But that's what I'm going to bill. And then I also have to state how much I'm billing for. And you can see here my billing rate on a daily basis for my residence is $103.72. So if I'm going to have a resident in my facility for a 30 day month, that's 30 times 103. I'm just going to do easy math.

00:14:08
Let's say it's $100. 30 times 100 is $3,000 for just the Medicaid portion. So that's what that's going to look like. And then if I were in Denver, this would be my rate. And so I can see right here my effective rates.

00:14:21
unit value and then if there's any extra comments that they need me to be aware of you can have multiple modifiers on here as well um we're not gonna get into that because you don't need to worry about that for assisted living um you're probably never gonna have to do more than one and oftentimes you don't even have to do any modifiers for assisted living

00:14:39
But this is what a fee schedule is going to look like when you're searching for it. You're trying to find what your rates are for your state, for Medicaid, for assisted living. You want to be looking for a chart that looks something very similar to this. Columns may be in a different area. It might...

00:14:55
Be colored something different. It's not going to have the Colorado logo up here at the top. But, you know, that's that's what you're going to see. And they will update them regularly. It's usually on the site, the website for whoever is is administering Medicaid in Colorado. That's the Department of Health Care.

00:15:14
policy and financing. Um, so that's who does this in, in Colorado. Um, HICPF is the acronym that we use for them, healthcare policy and financing, HCPF. Okay. Um, and then it's under home and community-based services. You do have to dig for this. It can be hard to find, um, some of these, these things. So what I want to show you now is how you can go and find the fee schedule for your state, um, online. So

00:15:44
And here's an example of a search term like this is exactly what I search. This is the result of what I found when I did the search. You want to search for state. So in this in this instance, Colorado, but it could be Texas, California, New York, New Hampshire, Florida, whatever. I'm not going to name all the states because that took me a while and I would miss several of them.

00:16:06
But state Medicaid program name. So in here, if you know the Medicaid program name, then put it in. If not, use Medicaid as your default. But you want to put state Medicaid program.

00:16:20
fee schedule for assisted living for the type of facility. So if it's called something different in your state, like in California, it's an RCFE. So I would put California Medi-Cal fee schedule for RCFE. That's what I would look for if I'm looking in California. If I'm in Texas, I would put Texas star plus fee schedule for assisted living, or it might be called something different in Texas, but I want to know what those things are.

00:16:48
And that's how I'm going to search for it. And then when you do that, you're going to find right here in this instance, the Colorado medical. I'm going to find the Colorado Medicaid fee schedule for residential care facilities. So right here, this is an example of what it looks like here. You can see the URL I have here.

00:17:08
Hick puff and I know who Hick puff is the the group that is administering Medicaid And then it's Colorado gov. It's it's a government website. So make sure you do that as well Don't don't just get this from some random site that has a blog about what Medicaid rates are because it's probably not current Make sure you go to the gov website for where you're looking at and then you can see here the last part of that URL is provider rates fee schedule and

00:17:32
So something like that, that's not going to be exactly what it is for your state, but something that has fee schedule in it is probably going to be your best bet in finding this. So if you can find that and then you would just click on it and then I don't have a view of exactly what that site looks like. And it can be confusing. There's a lot. When I look at the this Colorado.

00:17:53
Medicaid fee schedule website. It's long. There's the different waiver programs. There's the different processes. And so you might click in one and there's different years. It's kind of like this grid. And if I go and I click on it and I think I got the right one, but I can't find alternative care facilities, which is what I'm doing in Colorado, so assisted living or whatever it's going to be called in your state, then I may be on the wrong fee schedule. So I have to go in and dig into it.

00:18:21
That's where the Home and Community Based Services, or HCBS, the acronym there, is going to be really helpful because that's in a lot of different states. I see that one very consistently. Somebody reached out to me on Facebook just the other day, and they were asking for help in finding this in Louisiana. And what I found was I used this exact search term.

00:18:47
louisiana medicaid fee schedule for assisted living and it was under hcbs the home and community based services is where i was able to find that for louisiana so you can do this type of a search for any of the states that you're looking for and you're going to be able to find all that now if you need help as you're going through the process of just like trying to get answers like this you can't find it you're confused you don't know how to do it i would love to invite you to join our ali basics community

00:19:14
So in here we have resources, webinar recordings. There's a library of Q&A recordings. We have an active community where we're putting out weekly tips and you're getting your questions answered. Peer-to-peer networking. We have a Q&A session that is happening in two days. So if you get in there, you're going to be able to get access to me. It's just kind of a private Q&A session that we don't put on YouTube or anywhere else. You can ask whatever questions you have and those will be recorded and you can grab access to those as well.

00:19:41
So love this community. Go check it out. Assistedlivinginvesting.net slash basics is where you want to be going as you're trying to make some progress with that and getting your questions answered so you can launch your assisted living business in the next 12 months. So with that, I'm going to open it up for questions. For those of you that are here live, make sure you are typing in your questions and we'll get to that. But while you're typing, I want to remind you to like the video, subscribe and ring the bell as well.

00:20:09
So you get notified every time we put out content like this. We go live on Tuesdays, we put out content on Thursdays, and we put out a bunch of other stuff on all our social media platforms, all designed to help you launch your assisted living business in the next 12 months and help you get the answers to the questions that you have as you're trying to launch your assisted living business.

00:20:30
I need to run over here really quick and make sure I don't have any questions in our basics community that I haven't answered yet because I always want to prioritize those people and make sure they're getting their questions answered. And I just have to type in the right link so I can get to it. And of course, it's like asking for all the passwords right now. But...

00:20:58
As we're going through this, I hope that's been helpful for you in understanding how you can find Medicaid rates, the rates specifically for you and what you're trying to do as you're trying to just kind of launch your assisted living business.

00:21:14
and understand what's going on and helping you make some really good progress towards getting the answers that you need and helping you achieve your goals and your dreams. So with that, okay, I don't have any questions in there that I haven't gotten to already. So let's get over here. We've got a question from James. I've got to switch screens.

00:21:38
I was watching it live from somebody the other day and they had two people in it. And I was so jealous because man, doing this by myself can be hard sometimes. James, you got a question. Can you make a list of all the state specific links? That's a good question. It's something that I can definitely look into the problem with it, with me creating that type of a database. And it's something that if I do, it would be inside of our, inside of one of my programs.

00:22:05
Um, for sure. But the problem with me building out a list like that is they could change their links at any time and then it wouldn't be on there. So, um,

00:22:18
I will think about that and I will get back to you. It's a really good idea. My worry is maintaining it. And also like the search terms that I gave you here are going to work just as easy for you. But it's actually probably if we did something like that, we'd probably make it a part of the market research guide, which you can get if you go check out the launchpad bundle. And that's at assistedlivinginvesting.net slash launchpad.

00:22:45
Um, so in there, um, the market research guide, we update it on an annual basis and we're going to be working on that here in the next, um, probably next few weeks. We'll start gathering the data so we can get our next set of top 10, um,

00:23:00
top 10 markets for assisted living. And I've got some ideas on how to go deeper into that. And I think this is a great idea, James, to add to that. So that's where I think we'll put that one in and help people as they're trying to really make some good progress on it. Great suggestion. I appreciate that.

00:23:19
OK, any other questions? Go ahead and type those in now. Otherwise, I want to thank everybody for watching. I love doing these lives. I know this one, this video is a bit more technical and it.

00:23:34
will help you out i promise you but it's not like one of those those videos that everybody's just like you know climbing over each other to get to but for those of you that like ask this question often um or you have this type of a question i hope this has been helpful like this this video is very much specifically for for those of you that are trying to find those fee schedules and don't know how to do it um so i want to make sure that i'm getting you the information that you need um

00:23:59
Like, yeah, views and all the things with YouTube is great, but I want to be helpful. I want to help you out in launching your assisted living business, giving you actionable things to work on as you're trying to launch your assisted living business. So I want to thank everybody who has been here. Oh, we got another one from Nana. You squoze it in right as I was going to get out. Regarding SBA loans, must you work in the business to qualify or can you hire a manager for your RAL?

00:24:29
Um, that is a great question. You do not have to work in the business. So, um, when you're going through the process of getting the SBA loan, then what you're going to do is, uh, you're going to do the basics, right? Um, so go check out the launchpad bundle that I just mentioned, assistedlivinginvesting.net slash launchpad. I teach you all the basics that you're going to need. And these are the things that a lender is going to ask you for. So in there, you're going to have your business plan.

00:24:55
You need to have a very solid business plan in the business plan. You're going to design who is doing what, what roles are people going to play? And you want to be very specific in there that you are not going to be working in a business that you're going to hire a manager. There's going to be a section in there for management biographies.

00:25:14
if you have the manager in place, and sometimes a lender will require you to have the administrator or the manager in place before they give you the funds. So that can be a requirement doesn't have to be you. But they may require that person, you're going to want to just have a management biography for that individual. So that was an experience that we had. In my Idaho facility, we had to hire a new person. And we had to

00:25:39
Hire them and hope that they're going to sit and wait for us for two months while we work on closing the deal. So luckily she did that for us, which was great. But that's something that you want to be aware of. But what you do, what you want to make sure that you are doing is you're communicating your intent to the lender. And they may come back. Some lenders may require that you be the person that is in the business.

00:26:07
We had a requirement with our Colorado facility not to be in the business, but to try to find a property where like an investment property or like a second house, a vacation house in Colorado that we could go to if we needed to live there for a couple months while operations were going.

00:26:27
rough or something like that just like a worst case scenario so the way that it was worded gave us a little bit of wiggle room which was nice but there was a requirement by the lender that said you have to attempt to find a house in Colorado so that you live you can live there if needed so that was a thing for us being out of state

00:26:50
But you have to be specific. Don't try to hide something from a lender. Tell them what your goals are, what your plan is. Have that in your business plan. Make sure it's very clear because what you absolutely don't want to have happen is not tell them.

00:27:06
And then you get to the point where you've gone through their underwriting, you've gotten their board approvals, and now you're at your final needs section, which is the last thing that you're going to have to do. And in the final needs section, they find out that you're not going to be working in the business and they thought you were all along.

00:27:23
And, and there's no documentation for it anywhere. And those conversations will make sure you have things documented, save your emails, say, save all the conversations. And, and they're, and they're like, No, sorry, we thought you were going to be the one that was going to be working in the business. We're not gonna be able to fund this. And

00:27:42
months of work up to that point and getting a lender to say yes. And all of the heartache and everything, the effort that goes into that goes down the drain because you tried to hide the fact that you had no intent ever of working in the business. So you want to make sure you're upfront. It is better for them to say no to you upfront and not waste your time than to spend all of the time and effort and get to the finish line and then have them be like, Oh, you know, you lied to us. Nevermind. We don't want to work with you.

00:28:10
it ruins the relationship and we'll make it a lot. Like now you're going to be behind the eight ball. You might have to just like, you know, back out of the bill and potentially lose earnest money and things like that. So.

00:28:21
That would be my advice to you on that is you don't necessarily have to have it have to say that you're going to be working in the business to qualify for that for that SBA loan. But you do want to be clear on what your goals and intents are with the business. OK, so hopefully that helps you. James just looked up to California rates. Why are there four levels?

00:28:49
It is possible, because this is on a state basis, and I don't work in California, so I don't know specifics on California, but it is possible that there are levels for a resident, the amount of care that they need. And so,

00:29:06
one of them is going to be the highest, I don't know, level four is probably the highest, level one is the lowest, but maybe that's inverse. And so there will be rates that are specific to levels one through four based off of the amount of care that a resident needs. That is probably what it is, but there's also a possibility that there's a level of provider.

00:29:29
and that provider you have to get certified at the different levels and so a level four provider provides higher levels of care than a level one provider but as a level one provider maybe that's an rcfe and or an independent living and so you're not providing a lot of care so you have a lower rate so i would dig into that a little bit more and see if you can find something on their website that that tell you what that's going to look like but it's probably one of those two things

00:29:57
and this is where healthcare can be very confusing um and it can be hard to to kind of get into and and understand and navigate some of those things um it's not not always all it's not always clear and easy um and it can be difficult to just like you look at it you're like there's four levels i don't know why why are there four levels and it's confusing like

00:30:19
This happens in healthcare all the time. That's why my basics community, I think, is a great opportunity for you to get in there. You can share screenshots with me. I can answer the questions that you have. Go check that out. Assistedlivinginvesting.net slash basics. And would love to have you in there and help you out and navigate all of that. So, yeah. And Nana, you are absolutely welcome.

00:30:40
happy to help so uh with that i'm gonna i'll slow play it james and nana just in case you guys have questions you want to type in really quick uh but i want to thank uh everybody for joining us uh and thank you for the questions too i appreciate it um it's it's always awkward for me when i keep asking for questions nothing comes up and so i appreciate you jumping in and asking questions um

00:31:02
but uh thanks for watching thanks everybody for for being here uh and make sure you like the video subscribe ring the bell as well so you get notified when we put out content like this and go grab the free business plan checklist assistedlivinginvesting.net bp checklist to help you get the get the ball rolling and building that business foundation that you're going to need like we were talking about for nana about building that business plan so that you can really make some progress as you're launching your assisted living business

00:31:30
Does residential assisted living sound interesting to you, but you don't know how to get started at Assisted Living Investing? I'm here to help beginners like you launch their assisted living business in the next 12 months. I love helping and coaching people. It's one of my favorite things to do. So make sure you take me up on that. Go check out Assisted Living Investing.net slash basics. I'd love to help you out there. And if nothing else, get the free business plan checklist at Assisted Living Investing.net slash BP checklist. Thanks for watching and have a great day.