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Hello, everyone. This is Jacob Emerson with the
Becker's Payer Issues podcast. Thrilled today to be
joined by Jennifer Shermer, who's the vice president
of growth and community engagement and the interim
vice president of dual program integration at Blue
Shield of California's Promise Health Plan. Jen, thanks
so much for taking the time to be
with me on the podcast today. Hi, Jacob.
Thanks so much for having me. Absolutely. And
before we dive into everything we wanna talk
with you about, a lot of big changes
happening in the Medicaid space. Can you first
tell us, Jen, a little bit more about
yourself, your background in health care, and what
it is that you do today at Blue
Shield?
Yeah. Absolutely.
I began my career in health care
about twenty eight years ago as a customer
service representative.
And throughout my career since that time, I've
had
positions,
that range
in provider network management where I've negotiated provider
contracts for all provider types,
as well as held various operational roles
like claims,
configuration,
enrollment, and billing across all lines of business
and within a few different,
health care organizations
in California.
And while I have supported all lines of
business, I found my most fulfilling experiences
were those that involved the Medicaid program,
which is known as the Medi Cal program
here in California.
And I joined, Blue Shield of California Promise
Health Plan in 2020,
right at the onset of COVID.
And,
it was for an opportunity
that was going to exclusively
focus on the Medi Cal line of business.
And I was hired,
initially
serving as the senior director of Medi Cal
operations
before transitioning
into my current position in January
2023.
And in my current role here, I have
the exciting privilege to lead an incredible team
responsible for customer service,
provider engagement,
the duals special needs program integration,
and our business development teams.
And every day,
I have the privilege to work alongside such
talented professionals who are
extremely passionate and dedicated
about elevating member experiences,
strengthening our relationships with our healthcare providers,
and
driving the strategic growth of our health plan.
Wonderful. Well, appreciate that overview there, Jen. And
let's just dive right into what we're here
today to talk about, which is HR one,
one of the most impactful changes to the
Medicaid program since the program's inception, I think,
fair to say.
And we've been talking with insurers all over
the country about how how they're preparing for
these major changes coming down the pipeline,
some of the biggest going into effect in
in the coming next year.
So so before we dive into all that
and how how you're thinking about this at
Blue Shield and the Promise health plan, can
you first fill in our listeners who might
not be too familiar on,
what what's what's an overview of the impact
of HR one on your Medicaid members, And
what sort of the timeline that we're looking
at in terms of all the changes to
coverage,
that are that are coming down the pipe?
Yeah. Sure. I'm happy to. And I'll start
with just a brief overview of kind of
what HR one is.
And HR one is short for House Resolution
Bill one, also known as the one big
beautiful bill.
And it was signed into law last year
on the July 4,
and it was the first major bill
signed into law under this new federal administration.
And simply put, at a high level, HR
one changed federal budget laws,
including
large cross cutting changes affecting health care, taxes,
social programs,
and state budgets.
Medicaid or Medi Cal, again, as we call
it here in California,
is a public health insurance program in The
United States
that provides medical and long term coverage for
people
with low incomes and limited resources.
And from a federal program perspective,
Medicaid accounts for about nine to 10% of
the federal spend, making it the third
largest federal program.
And H. R. One made the largest changes
to the Medicaid program that we've seen in
decades.
It's affecting eligibility,
coverage, and financing.
And the federal changes to the Medicaid
program have direct
material effects on states because
Medicaid is a joint
federal and state program
that states administer and also help finance.
So changes to the federal budget laws directly
affect state budgets and states' Medicaid operations.
And here in California,
the Medicaid program,
or Medi Cal,
has been impacted by both federal and state
policy changes
that impact,
who remains eligible for coverage,
how easy people can stay enrolled,
and continue to have access to care,
across communities in California.
Understood. I appreciate that that overview of the
law of the new law, Jen.
Specifically
for Californians,
for your for your Promise health plan members,
what is this looking like for them?
And, ultimately, how are you preparing internally, to
adapt to to some of the changes?
Yeah. So some of the changes to the
program have already gone into effect, and others
are close on the horizon. So I'll start
with an example
of a state policy change
that has already gone into effect, and then
we can talk about,
examples,
on the federal policy side.
So beginning,
first of this year,
California froze new enrollments into full scope medical
for undocumented
adults age 19 and older.
And full scope means comprehensive medical coverage, such
as primary care, specialty care, and prescription drugs,
not just emergency services and prenatal services.
And you may recall back in 2024,
California became the first state
to provide Medi Cal to all income eligible
residents regardless of their
immigration status.
So the new policy change to freeze enrollments
for undocumented adults
is driven by budgetary and fiscal constraints, meaning
it's a response to state budget deficit
and rising state only Medi Cal costs.
And also starting on 01/01/2026,
the Medi Cal asset limit
was reinstated.
This means that when determining eligibility,
Medi Cal will now check to verify what
people own,
not just their income.
So some of your listeners may remember that
in January
2024,
California fully eliminated
the Medi Cal asset test.
And now after two years,
California has brought that back.
And then an example
of,
kind of federal policy changes that will soon
go into
effect include,
starting in October,
so 10/01/2026,
there will be changes to who is considered
a qualified immigrant
for federally funded medical. So HR one narrows
noncitizen
eligibility for federally funded Medi
Cal, and this change means that many lawfully
residing immigrants who are currently eligible for full
scope Medi Cal will no longer be eligible.
They will only be eligible for restricted scope
medical,
which covers emergency and pregnancy related services.
And this policy change affects refugees,
asylees,
and victims of human trafficking, to name a
few. So another federal policy change
requirements
and moving from an annual to a six
month renewal requirement for certain adult groups,
which go into effect January
2027.
So under the new federal work and community
engagement requirements,
certain groups of adults age 19 to 64
must show evidence that one of five requirements
are met.
And those can range from,
being employed at least eighty hours per month
and meet a certain monthly income threshold, threshold,
or they have performed eighty hours of community
service per month.
And there's a couple other,
elements that they can meet the criteria for
that. But I do wanna stress that the
new work and community engagement
requirement only applies to certain adults age 19
to 64.
And this group is referred to as the
new adult group in California.
It was formally known as the Medicaid expansion
adult population
under the Affordable Care Act.
So these are the individuals and the adults
with no dependents
whose annual income is below a 138%
of the federal poverty level, which is about
$21,600.
And,
as part of this program, there are adult
populations who are exempt
from the work and community engagement requirements.
And those folks would include individuals
who are pregnant or up to twelve months
postpartum,
foster youth and former foster youth under the
age of 26, and several more.
And a final point I wanna mention is
that eligibility
redeterminations
will increase from once a year to every
six months
for that new adult group who is subject
to the new work and community engagement requirements.
And we're still waiting for additional federal and
state guidance
on how medical members will show that they've
met the work and community engagement requirements
and what the renewal process changes will be.
So more to come on that.
I mean, it really is mind boggling, though,
when you when you detail all that, Jen.
And I know that's just a quick overview
of all the changes happening that are coming,
have happened,
from from a immigrant perspective, from the work
requirements perspective, so many details there, and then
still waiting on guidance for eligibility redeterminations.
So I wonder, internally, how has this changed
your day to day, your role,
within the Promise Health Plan? How how as
a company are you preparing for all of
this? And then, of course, communicating
all of this to what is already a
very vulnerable population.
Yeah. And I think you're absolutely right. They
are significant changes, and I think it's also
important to note that all of these changes
are significant
undertakings for all of the states.
If you think about what they have to
set up,
in terms of in infrastructure
so they can track these work hours, these
exemptions,
and the new biannual renewal process. So,
it it is a lot. It's a it's
a heavy burden on the states.
But with respect to how Blue Shield Promise
is responding to these changes,
and how we are our members are impacted.
I just,
wanna remind the listeners that in,
in California, the Medi Cal program covers
approximately
14,700,000
individuals.
To put that into perspective, that's one in
three Californians
are currently
receiving Medi Cal services and benefits.
And the California Department of Healthcare Services
anticipates the new federal provisions will increase administrative
workload and the rate of procedural and
administrative coverage for administrative reasons,
not because they are ineligible.
And those new changes are expected to impact
up to 2,000,000
medical members, which is about 14%
of that medical population here in California.
For Blue Shield Promise, we know these changes
will have a significant impact on our members
and communities
and providers that we serve.
Today, we're currently providing Medi Cal services to
roughly 550,000
members
in Los Angeles and San Diego Counties,
which are two of the most populous
culturally and linguistically diverse counties in California.
The good news is that we have been
preparing for these program changes,
and our experience positions us well to support
our members for for what's ahead.
Some of the specific
programs and initiatives that promise,
that promise is embarking on to support
our members through these changes
are really around three key areas. The first
one is high touch support and outreach.
The second is around innovation and technology solutions.
And the third is stakeholder connections and collaboration.
And we have several programs that
And we have several programs
that deliver high catch support and outreach to
our members,
including our growth and retention call center and
community resource centers.
Both programs are staffed by bilingual,
bi cultural specialists who are experts in medical
eligibility
and enrollment,
and many have similar lived experiences to our
members.
And they can quickly make connections and build
trust and confidence. They know how to navigate
around the system,
and they know how to navigate within their
own communities.
We are also leveraging digital platforms
and culturally relevant media channels
to get information to our members, community leaders,
and others who serve as trusted advisers to
our members and communities.
Promise has teams that are out in,
in the community. We are at community events.
We're on college campuses,
at low income housing complexes,
and other community places conducting outreach and offering
enrollment
and renewal assistance,
wherever we can.
We've got our provider engagement team who visits
providers
nearly every day, offering them information,
training,
and resources to help their patients navigate the
medical enrollment and renewal processes.
And,
we we are making sure that at every
touch point a member has with Blue Shield
Promise,
they are being reminded to update their contact
information,
recertify,
and reach out to us for help with
the medical renewal process. We understand it can
be challenging and frustrating,
but we are here to help them and
support
them. And, Jen, let me you know, you
you said something really,
really interesting
at the start of your your last answer
there about how more people are gonna be
losing coverage because of administrative issues and not
because they're actually ineligible
for Medicaid, which is really unfortunate. And I
I I wonder
from from the human and from the emotional
perspective of all of this, what are you
hearing on the ground level from your members,
in terms of their understanding of what's going
on, how coverage needs to be maintained.
Maybe they be are gonna be become ineligible.
What what are you hearing, from members directly
about all of this?
Well, I think we can all agree that
health care is already complicated,
and these recent policy changes are adding yet
another layer of complexity for patients and families.
Our members, providers, and community partners have expressed
concerns
and are worried about
understanding the different rule changes
and,
potentially losing their coverage over a paperwork mishap
as opposed to eligibility.
And they're also concerned about potential disruptions in
care.
And for our members who face barriers, these
changes make an already complicated system feel even
harder to navigate.
And that's why we are focused on reaching
our members where they are, helping them understand
what's changing, and providing them with hands on
support so they can keep their medical coverage.
And, Jen, let me let me also touch
on you know, as as we mentioned at
the start of the conversation today,
you're interim VP of duals program integration at
at the Promise Health Plan as well.
How are you approaching your role to best
integrate Medicare and Medi Cal offerings right now?
Does that fit into what we're talking about,
with HR one? And and do you have
any best possible approaches you'd share in terms
of coordination,
accessibility,
more affordable
offerings overall?
Yeah. So our approach is ultimately to create
an environment where coordination,
access, and affordability
are sustainable
and practical for dual eligible members.
And we are working to ensure,
that Medicare and Medi Cal
is seamless
for our members and providers.
And we're really focused on streamlining
our operations and workflows
so teams are working together
and providing unified support.
We're making coverage easier to understand and access
with clear communication
and a no wrong door approach
to servicing every one of our members.
We are looking at reducing out of pocket
costs,
aligning payments, and ensuring members stay covered through
their life changes.
Looking at supporting clear, consistent rules at state
and federal levels
to simplify enrollment and keep coverage. So really
looking to strengthen policy advocacy
and,
and making sure that we've got support in
that in that area as well.
Wonderful. Well well, Jen, before we go today,
you've got a lot of other colleagues from
around the country listening and facing similar challenges,
trying to figure out and navigating
all these same policy changes.
What else would you share with them, or
is there any bits of advice you'd offer,
as you as you navigate similarly?
Yeah. So I I would close,
just with a couple final thoughts. First,
for individuals who live in California, one of
the best ways to stay informed about the
Medi Cal program changes
is through the Department of Health Care Services
coverage
ambassador program.
And the coverage ambassador program was launched
at the end of the COVID nineteen public
health emergency to help Medi Cal members
understand,
enroll, and keep their Medi Cal coverage.
And anyone can become a coverage ambassador.
There is no cost or certification requirement,
and the program is voluntary and unpaid. So
you can sign up to to be a
coverage ambassador at the DHCS website.
And once you enroll, you will receive updates,
toolkits, and outreach materials
to help you and others stay informed about
Medi Cal renewals and policy changes.
So you don't have to be a member.
You can be a community partner. You can
be a provider.
You could be a member. But anybody, any
health plan representative that wants to stay up
to speed,
that's
in California, that is the best way to
stay current
with what's happening with all of the changes.
Second, if you haven't already, I'd encourage you
to connect with community organizations that are serving
your members.
Identify those community leaders who are trusted messengers,
and work with your provider network to outreach
to members early and often about the changes
in the Medicaid program.
And if you have the resources,
invest in high touch support services through navigators
and community health workers, technology solutions,
and multilingual
communications channels
to engage members. It really shouldn't be in
in either or. You know, in an ideal
state, it should be a complimentary approach
and not a trade off.
And finally, I would just remind us all
that we've navigated
hard moments in Medicaid before,
and our resilience,
ingenuity, and dedication
to the people we serve carries us forward.
Medicaid is complex and challenging,
but this work is in our DNA, and
we rise to the challenge every time.
Wonderful. I think that's a great last place
to leave things. So, Jen, I wanna thank
you for taking the time to be with
us here on the podcast and for sharing
your insights with our listeners. We really appreciate
it.
Absolutely. Thanks again for having me.
Anytime. And and to our listeners, if you'd
like to listen to more podcasts from Becker's
HealthCare, you can visit beckershospitalreview.com.