Medicaid & Medicare in Assisted Living: Essential Insights
Oct 14, 2024
Navigating the complexity of Medicaid and Medicare can be difficult, particularly in the context of assisted living facilities. In this blog, we will delve into the complexities of these important programs and show how they relate to assisted living. Understanding Medicaid and Medicare is vital for anyone working in this industry since it affects billing, compliance, and overall service delivery.
Medicaid provides an important lifeline for assisted living services by supporting many care components. However, it's crucial to understand that Medicare does not cover assisted living services, which is a widespread misperception that can be confusing. Medicaid is administered differently in each state, with some states managing it directly and others via managed care organizations. To successfully navigate these processes, you need to be completely aware of your state's standards, ensuring you can efficiently handle billing and compliance inside your assisted living facility.
Check out the video, too:
Can You Bill Medicaid for Assisted Living Services?
One of the most common questions is whether assisted living services can be billed through Medicaid. The answer is an emphatic YES. However, the compensation process differs in each state, with different processes and reimbursement rates.
State-Set Reimbursement Rates
Each state uses a budgeting process to calculate Medicaid reimbursement rates for assisted living services. These charges are usually set at a daily rate for each resident based on the care they receive.
Can You Bill Medicare for Assisted Living Services?
Compared to Medicaid, Medicare does not cover long-term care, such as the services provided in an assisted living facility. Medicare is intended for short-term care, including hospital stays (Medicare Part A), outpatient services (Medicare Part B), and prescription medicines (Medicare Part D). As a result, you cannot bill Medicare for long-term care given in assisted living facilities. However, residents in assisted living homes may have Medicare for the other services they need, including visiting their primary care provider, paying for their medications, or going to a rehab facility.
Administration of Medicaid
Understanding who administers Medicaid in your state is important. Generally, there are two main administrators: the state or a Managed Care Organization (MCO).
State Administration
In some states, Medicaid is administered directly by the state government. You will submit your claims directly to the state's Medicaid office, which will process and reimburse you for the services provided.
Managed Care Organizations (MCOs)
In other states, Medicaid is managed by MCOs, which are private corporations (often healthcare payors, like health insurance companies) contracted by the state to provide Medicaid payment processing services. These organizations will receive and process the claims and often provide more efficient services.
Navigating Multiple MCOs
In states with several MCOs, residents select their MCO. Thus, you may need to contract with multiple MCOs to accommodate all residents regardless of their Medicaid carrier. While it may feel intimidating, the initial setup process with these MCOs is the most difficult part. Once registered, everything else becomes much easier and more straightforward.
Key Takeaways
It is important to understand how Medicaid and Medicare work in assisted living. Assisted living services can be billed to Medicaid but not to Medicare. Medicaid administration varies by state and may include direct governmental management or managed care organizations. You must know your state's specific criteria and process to successfully navigate Medicaid in your state.
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Transcript
00:00:01
[Music] hey guys it's brandon gustafson welcome back to assisted living investing i have you on the channel today just wanted to remind you please visit me on assistedlivinginvesting.net i would love to see you over there for the free resources and to subscribe to my newsletter for future content make sure you like comment and subscribe to the video uh ring that bell so that you get notified when i get new content up here and then make sure you're following me on all my social media platforms
00:00:38
instagram tick tock facebook uh instagram twitter all of them just make sure you follow me there i have links uh and and uh things in the bio uh down below so make sure you follow me there i'd love to see you over there a quick recap our in our last video we went over what are medicaid and medicare i went over kind of in depth what those two programs are how they work and who qualifies for them make sure you go and watch that over here i'll have it linked in the up above make sure you click on
00:01:07
that so you can get an understanding of what it is because today we're going to get into how medicaid and medicare work specifically for assisted living so we'll start diving into this and get more specific into the industry that is assisted living so you have a better understanding of how this how those programs are going to impact you uh with with the work that you're trying to do as you start up your facility or even if you own a facility helping you kind of understand exactly how they work
00:01:34
so that you can then become a medicaid provider um and and get reimbursed for your work there so the first question is can i build medicaid for assisted living services that's a great question i get that a lot uh when i'm talking to people they ask me uh the process for for billing medicaid can can i get reimbursed for medicaid and the answer is yes you can build medicaid for assisted living services you're going to be able to get reimbursed for that reimbursement rates for medicaid for assisted living are set
00:02:04
by the state in your state they could be called a residential care facility it could be assisted living facility each state kind of has a little bit of a different things a different term that they call the the assisted living program so you'll have to figure out exactly what that is but once you're able to to figure it out you're able to go through and get reimbursed for it and that reimbursement rate is set by the state through their budgeting process and it is a daily rate so in an upcoming video i'm going to get
00:02:37
exactly into how medicaid reimbursement works but at a high level you are reimbursed for a daily rate for each resident at the facility oftentimes this is set up through a community waiver program i mentioned the new choice waiver program in utah in my last video but the process is generally the same so you're going to get in you'll you'll build medicaid you'll get reimbursed that daily rate and i'll get it more into detail in an upcoming video on exactly what that process looks like um and how you can
00:03:10
get reimbursed for medicaid for your assisted living but the answer to can you build medicaid for assessing living services is yes you can which is great the next question is can i bill medicare for assisted living services and the short answer is no so medicare does not cover institutional care or long-term care and that's where assisted living kind of falls in the scheme of the healthcare landscape it falls into this area where it's um you know your residents are staying there long term
00:03:39
they are they are living at your facility um they are not there for you know three or four days for an inpatient visit which would be medicare part a they're not just coming in to do a quick surgery or getting a quick checkup like they would without patient care which would be medicare part b while you are administering medications to the residents you are not the pharmacy and that would be medicare part d um so you're not getting any of those reimbursements you are receiving reimbursement for the care that you
00:04:14
provide and that comes directly from the resident or through a medicaid program your residents especially if you're an elderly care facility are likely going to have medicare um so like that that is that's very possible um we talked about last video you qualify for medicare at the age of 65. so in an elderly care facility most of your residents will be on medicare for their other care needs but for the long-term care that you are providing you will not get reimbursed for that which is unfortunate so no do can you
00:04:46
build medicare for assisted living services you cannot um unfortunately so let's get into who administers medicaid since that's the program that you're going to be able to get reimbursed for the services that you're offering uh the services that you're rendering uh let's get into that so sometimes um the state is gonna be the person that administers like the the actual state the state of utah the state of colorado the state of idaho they will administer medicaid they take care you build
00:05:14
directly to the state they process that claim and then they pay you directly from the state it comes out of there out of their budget so that is one option the other option is what is called a managed care organization or m-c-o-m as in mary m-c-o you might see that that term you might be familiar with that you may have heard of it some time in the past basically what a managed care organization is what an mco is is they are contracted out by the state to administer the the medicaid program and these can be anything they they are
00:05:50
generally specific to a type of care so i worked for optima at one point and we were the managed care organization for mental health claims in the state of utah in salt lake county so it was very niched and went down there are mcos that are going to administer things that are specific to assisted living so in idaho we work with blue cross of idaho and we work with molina so these mcos are often you can tell by the names of those organizations i just gave you they're often a health insurance payer so it's a big healthcare
00:06:23
insurance company and then they have a branch of their organization that is an mco and they go out and they bid for these contracts with the state the state will award them those contracts and then the mco will administer the plan so you work directly with that with that mco to get registered with them um you you bill them and then the way that it works is um that mco receives your claim um they process it they send it up to the state the state says thank you um yep you get reimbursed for x amount of money and and
00:07:00
so that mco receives the money and then they pass it on to you and they pay you which i know that process that i just explained um might seem like um just overbearing like maybe just too much stuff um like too many too many balls in the air a lot of unnecessary work that's going on and that might be the case but mcos i in my experience are are much more efficient with the way that they're processing your claims they're easier to deal with they have systems in place they're they're just a lot easier to to work
00:07:34
with they're more far more responsive and a lot of that is because they come from these larger health insurance carriers so they have experience dealing with claims and dealing with customer service and and things like that so their billing process is a lot more streamlined payment is more regular they're just a little bit easier to deal with um and it just takes a little bit extra time but it's not that big of a deal on top of that um you may end up having multiple mcos in the state so in idaho
00:08:03
for example for us we have to our residents so the residents are the ones that choose who they are going to have administered their plan so you don't have a lot of stay in it you could you could tell them i only accept residents who have medicaid through ex provider you could do that but the the residents are the ones that are choosing who their provider is so if you're going to accept any medicaid resident you'll want to identify who their provider is and then make sure that you are contracted with that that
00:08:34
provider whether it's the state or the mco so you can even have multiple mcos in a state and that's going to require you to register with multiple payers and bill multiple payers so it does create a little bit of extra work on your end it's not difficult it's not a hard process to do but it is something to be aware of for example in in idaho we deal with blue cross of idaho and molina and the state of idaho we have residents that fall under all three of those buckets we have to bill three different payers
00:09:07
which seems like a lot of work now that we have it all set up and everything's approved it's not that hard it's relatively easy a lot of times they they kind of streamline the process for you once you get into their ecosystem so it's a lot of upfront work once you get there though it's it's really not that hard um to do but you'll want to just remember that the resident is the one that has the the choice to choose who is going to administer their their medicaid plan so
00:09:36
just to recap our video today we've been talking about what medicaid and medicare are and how they apply to assisted living we went over can i build medicaid for assisted living services which yes you can can i bill medicare for assisted living services and no you cannot and then who administers medicaid in the states that you're in and just kind of gave an overview of that next time i'm going to dive into how you can get certified as a medicaid provider just kind of give you an overview of the
00:10:03
process so you understand exactly kind of how it works what it looks like contracting with an mco contracting with the state what that process is and i'd love to have you in that video as well so you can kind of just continue learning about this process of of working with medicaid working with different health care payers and and providers and and just kind of getting a good understanding of exactly how this all works especially in this niche of of assisted living make sure that you are commenting down
00:10:33
below if this this content is helpful for you i'd love to hear from you uh let me know if i missed something i would love to to hear from people that have a lot of experience with medicaid because it's different in every state i'm just speaking from the experience that i have in the states that i've worked with but i know that it's different in different states i was talking with somebody in mississippi the other day and there's a requirement that you have to be a provider for two years before you can
00:10:56
be a medicaid provider so there's just a lot of different rules in each state and how things are administered so you want to make sure that you are contacting the department of health in your state to learn what it looks like but make sure you comment down below let me know if this content is helpful make sure you subscribe give me a big thumbs up on the like ring that bell so that you get notified when i put out future content and also make sure you're following me on me on all my social
00:11:21
media platforms visit me on assistedlivinginvesting.net where you can get some free resources and join my mailing list for future content and i'll look forward to seeing you in the next video thanks for watching and have a great one see ya [Music] you
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