Speaker 0: This is where health insurance leadership comes together. Becker's fourth annual spring payer issues roundtable brings together over 400 payer and health plan executives and more than 100 speakers to Chicago April. This year's event includes keynote conversations with the industry's top leaders and former president George w Bush. For the full agenda and event details, visit beckershospitalreview.com and click on the events tab in the upper right. We're looking forward to hosting you here in Chicago.

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.

Speaker 1: Hi, Jacob. Thanks so much for having me.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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.

Speaker 1: 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

Speaker 0: provisions will increase administrative workload and the

Speaker 1: 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

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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.

Speaker 1: Absolutely. Thanks again for having me.

Speaker 0: Anytime. And and to our listeners, if you'd like to listen to more podcasts from Becker's HealthCare, you can visit beckershospitalreview.com.