Latest / Becker’s Payer Issues Podcast / Navigating HR1 and Protecting Medi-Cal Coverage with Jennifer Schirmer

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Navigating HR1 and Protecting Medi-Cal Coverage with Jennifer Schirmer · Becker’s Payer Issues Podcast

0:02
This is where health insurance leadership comes together.
0:05
Becker's fourth annual spring payer issues roundtable brings
0:08
together over 400
0:10
payer and health plan executives and more than
0:13
100 speakers to Chicago April.
0:16
This year's event includes keynote conversations with the
0:19
industry's top leaders and former president George w
0:23
Bush. For the full agenda and event details,
0:25
visit beckershospitalreview.com
0:27
and click on the events tab in the
0:29
upper right. We're looking forward to hosting you
0:31
here in Chicago.
0:33
Hello, everyone. This is Jacob Emerson with the
0:36
Becker's Payer Issues podcast. Thrilled today to be
0:39
joined by Jennifer Shermer, who's the vice president
0:41
of growth and community engagement and the interim
0:44
vice president of dual program integration at Blue
0:46
Shield of California's Promise Health Plan. Jen, thanks
0:49
so much for taking the time to be
0:51
with me on the podcast today. Hi, Jacob.
0:53
Thanks so much for having me. Absolutely. And
0:55
before we dive into everything we wanna talk
0:57
with you about, a lot of big changes
0:59
happening in the Medicaid space. Can you first
1:01
tell us, Jen, a little bit more about
1:03
yourself, your background in health care, and what
1:05
it is that you do today at Blue
1:07
Shield?
1:08
Yeah. Absolutely.
1:09
I began my career in health care
1:12
about twenty eight years ago as a customer
1:15
service representative.
1:17
And throughout my career since that time, I've
1:19
had
1:20
positions,
1:22
that range
1:23
in provider network management where I've negotiated provider
1:26
contracts for all provider types,
1:29
as well as held various operational roles
1:32
like claims,
1:33
configuration,
1:34
enrollment, and billing across all lines of business
1:38
and within a few different,
1:40
health care organizations
1:41
in California.
1:42
And while I have supported all lines of
1:44
business, I found my most fulfilling experiences
1:48
were those that involved the Medicaid program,
1:51
which is known as the Medi Cal program
1:53
here in California.
1:55
And I joined, Blue Shield of California Promise
1:59
Health Plan in 2020,
2:01
right at the onset of COVID.
2:03
And,
2:04
it was for an opportunity
2:06
that was going to exclusively
2:08
focus on the Medi Cal line of business.
2:10
And I was hired,
2:12
initially
2:13
serving as the senior director of Medi Cal
2:15
operations
2:16
before transitioning
2:18
into my current position in January
2:20
2023.
2:22
And in my current role here, I have
2:25
the exciting privilege to lead an incredible team
2:29
responsible for customer service,
2:32
provider engagement,
2:33
the duals special needs program integration,
2:37
and our business development teams.
2:40
And every day,
2:41
I have the privilege to work alongside such
2:43
talented professionals who are
2:46
extremely passionate and dedicated
2:48
about elevating member experiences,
2:51
strengthening our relationships with our healthcare providers,
2:54
and
2:55
driving the strategic growth of our health plan.
2:59
Wonderful. Well, appreciate that overview there, Jen. And
3:02
let's just dive right into what we're here
3:04
today to talk about, which is HR one,
3:07
one of the most impactful changes to the
3:09
Medicaid program since the program's inception, I think,
3:12
fair to say.
3:14
And we've been talking with insurers all over
3:16
the country about how how they're preparing for
3:18
these major changes coming down the pipeline,
3:21
some of the biggest going into effect in
3:23
in the coming next year.
3:25
So so before we dive into all that
3:27
and how how you're thinking about this at
3:29
Blue Shield and the Promise health plan, can
3:32
you first fill in our listeners who might
3:34
not be too familiar on,
3:36
what what's what's an overview of the impact
3:38
of HR one on your Medicaid members, And
3:41
what sort of the timeline that we're looking
3:43
at in terms of all the changes to
3:44
coverage,
3:45
that are that are coming down the pipe?
3:48
Yeah. Sure. I'm happy to. And I'll start
3:50
with just a brief overview of kind of
3:52
what HR one is.
3:54
And HR one is short for House Resolution
3:58
Bill one, also known as the one big
4:00
beautiful bill.
4:01
And it was signed into law last year
4:04
on the July 4,
4:06
and it was the first major bill
4:09
signed into law under this new federal administration.
4:13
And simply put, at a high level, HR
4:15
one changed federal budget laws,
4:19
including
4:20
large cross cutting changes affecting health care, taxes,
4:24
social programs,
4:25
and state budgets.
4:28
Medicaid or Medi Cal, again, as we call
4:30
it here in California,
4:32
is a public health insurance program in The
4:35
United States
4:36
that provides medical and long term coverage for
4:40
people
4:41
with low incomes and limited resources.
4:44
And from a federal program perspective,
4:47
Medicaid accounts for about nine to 10% of
4:50
the federal spend, making it the third
4:53
largest federal program.
4:56
And H. R. One made the largest changes
4:58
to the Medicaid program that we've seen in
5:00
decades.
5:01
It's affecting eligibility,
5:03
coverage, and financing.
5:06
And the federal changes to the Medicaid
5:09
program have direct
5:10
material effects on states because
5:13
Medicaid is a joint
5:15
federal and state program
5:17
that states administer and also help finance.
5:21
So changes to the federal budget laws directly
5:24
affect state budgets and states' Medicaid operations.
5:29
And here in California,
5:31
the Medicaid program,
5:33
or Medi Cal,
5:34
has been impacted by both federal and state
5:38
policy changes
5:39
that impact,
5:41
who remains eligible for coverage,
5:44
how easy people can stay enrolled,
5:47
and continue to have access to care,
5:50
across communities in California.
5:53
Understood. I appreciate that that overview of the
5:56
law of the new law, Jen.
5:58
Specifically
5:59
for Californians,
6:01
for your for your Promise health plan members,
6:04
what is this looking like for them?
6:06
And, ultimately, how are you preparing internally, to
6:08
adapt to to some of the changes?
6:11
Yeah. So some of the changes to the
6:13
program have already gone into effect, and others
6:16
are close on the horizon. So I'll start
6:18
with an example
6:20
of a state policy change
6:22
that has already gone into effect, and then
6:24
we can talk about,
6:26
examples,
6:27
on the federal policy side.
6:30
So beginning,
6:33
first of this year,
6:34
California froze new enrollments into full scope medical
6:38
for undocumented
6:39
adults age 19 and older.
6:42
And full scope means comprehensive medical coverage, such
6:46
as primary care, specialty care, and prescription drugs,
6:50
not just emergency services and prenatal services.
6:53
And you may recall back in 2024,
6:56
California became the first state
6:58
to provide Medi Cal to all income eligible
7:02
residents regardless of their
7:04
immigration status.
7:05
So the new policy change to freeze enrollments
7:08
for undocumented adults
7:10
is driven by budgetary and fiscal constraints, meaning
7:14
it's a response to state budget deficit
7:18
and rising state only Medi Cal costs.
7:22
And also starting on 01/01/2026,
7:26
the Medi Cal asset limit
7:28
was reinstated.
7:30
This means that when determining eligibility,
7:34
Medi Cal will now check to verify what
7:36
people own,
7:38
not just their income.
7:40
So some of your listeners may remember that
7:42
in January
7:43
2024,
7:45
California fully eliminated
7:46
the Medi Cal asset test.
7:49
And now after two years,
7:51
California has brought that back.
7:54
And then an example
7:55
of,
7:56
kind of federal policy changes that will soon
7:59
go into
8:01
effect include,
8:02
starting in October,
8:04
so 10/01/2026,
8:07
there will be changes to who is considered
8:09
a qualified immigrant
8:12
for federally funded medical. So HR one narrows
8:16
noncitizen
8:17
eligibility for federally funded Medi
8:20
Cal, and this change means that many lawfully
8:23
residing immigrants who are currently eligible for full
8:26
scope Medi Cal will no longer be eligible.
8:30
They will only be eligible for restricted scope
8:33
medical,
8:34
which covers emergency and pregnancy related services.
8:38
And this policy change affects refugees,
8:41
asylees,
8:42
and victims of human trafficking, to name a
8:43
few. So another federal policy change
8:57
requirements
8:59
and moving from an annual to a six
9:01
month renewal requirement for certain adult groups,
9:04
which go into effect January
9:07
2027.
9:08
So under the new federal work and community
9:11
engagement requirements,
9:13
certain groups of adults age 19 to 64
9:16
must show evidence that one of five requirements
9:19
are met.
9:21
And those can range from,
9:23
being employed at least eighty hours per month
9:27
and meet a certain monthly income threshold, threshold,
9:31
or they have performed eighty hours of community
9:33
service per month.
9:34
And there's a couple other,
9:36
elements that they can meet the criteria for
9:39
that. But I do wanna stress that the
9:42
new work and community engagement
9:44
requirement only applies to certain adults age 19
9:48
to 64.
9:49
And this group is referred to as the
9:51
new adult group in California.
9:54
It was formally known as the Medicaid expansion
9:57
adult population
9:58
under the Affordable Care Act.
10:01
So these are the individuals and the adults
10:03
with no dependents
10:05
whose annual income is below a 138%
10:09
of the federal poverty level, which is about
10:12
$21,600.
10:15
And,
10:16
as part of this program, there are adult
10:18
populations who are exempt
10:21
from the work and community engagement requirements.
10:24
And those folks would include individuals
10:27
who are pregnant or up to twelve months
10:29
postpartum,
10:31
foster youth and former foster youth under the
10:34
age of 26, and several more.
10:38
And a final point I wanna mention is
10:40
that eligibility
10:41
redeterminations
10:43
will increase from once a year to every
10:45
six months
10:47
for that new adult group who is subject
10:49
to the new work and community engagement requirements.
10:53
And we're still waiting for additional federal and
10:56
state guidance
10:57
on how medical members will show that they've
10:59
met the work and community engagement requirements
11:03
and what the renewal process changes will be.
11:07
So more to come on that.
11:08
I mean, it really is mind boggling, though,
11:10
when you when you detail all that, Jen.
11:12
And I know that's just a quick overview
11:14
of all the changes happening that are coming,
11:16
have happened,
11:18
from from a immigrant perspective, from the work
11:20
requirements perspective, so many details there, and then
11:24
still waiting on guidance for eligibility redeterminations.
11:28
So I wonder, internally, how has this changed
11:30
your day to day, your role,
11:33
within the Promise Health Plan? How how as
11:35
a company are you preparing for all of
11:37
this? And then, of course, communicating
11:39
all of this to what is already a
11:41
very vulnerable population.
11:44
Yeah. And I think you're absolutely right. They
11:46
are significant changes, and I think it's also
11:48
important to note that all of these changes
11:51
are significant
11:52
undertakings for all of the states.
11:55
If you think about what they have to
11:56
set up,
11:57
in terms of in infrastructure
12:00
so they can track these work hours, these
12:02
exemptions,
12:04
and the new biannual renewal process. So,
12:07
it it is a lot. It's a it's
12:09
a heavy burden on the states.
12:11
But with respect to how Blue Shield Promise
12:14
is responding to these changes,
12:17
and how we are our members are impacted.
12:20
I just,
12:21
wanna remind the listeners that in,
12:24
in California, the Medi Cal program covers
12:27
approximately
12:28
14,700,000
12:30
individuals.
12:32
To put that into perspective, that's one in
12:34
three Californians
12:35
are currently
12:36
receiving Medi Cal services and benefits.
12:39
And the California Department of Healthcare Services
12:43
anticipates the new federal provisions will increase administrative
12:44
workload and the rate of procedural and
12:54
administrative coverage for administrative reasons,
12:57
not because they are ineligible.
13:00
And those new changes are expected to impact
13:02
up to 2,000,000
13:04
medical members, which is about 14%
13:07
of that medical population here in California.
13:10
For Blue Shield Promise, we know these changes
13:13
will have a significant impact on our members
13:16
and communities
13:17
and providers that we serve.
13:20
Today, we're currently providing Medi Cal services to
13:23
roughly 550,000
13:26
members
13:27
in Los Angeles and San Diego Counties,
13:30
which are two of the most populous
13:32
culturally and linguistically diverse counties in California.
13:37
The good news is that we have been
13:39
preparing for these program changes,
13:41
and our experience positions us well to support
13:44
our members for for what's ahead.
13:47
Some of the specific
13:49
programs and initiatives that promise,
13:53
that promise is embarking on to support
13:56
our members through these changes
13:58
are really around three key areas. The first
14:01
one is high touch support and outreach.
14:04
The second is around innovation and technology solutions.
14:09
And the third is stakeholder connections and collaboration.
14:10
And we have several programs that
14:13
And we have several programs
14:15
that deliver high catch support and outreach to
14:18
our members,
14:19
including our growth and retention call center and
14:22
community resource centers.
14:24
Both programs are staffed by bilingual,
14:27
bi cultural specialists who are experts in medical
14:30
eligibility
14:31
and enrollment,
14:33
and many have similar lived experiences to our
14:36
members.
14:36
And they can quickly make connections and build
14:39
trust and confidence. They know how to navigate
14:42
around the system,
14:43
and they know how to navigate within their
14:45
own communities.
14:47
We are also leveraging digital platforms
14:50
and culturally relevant media channels
14:53
to get information to our members, community leaders,
14:56
and others who serve as trusted advisers to
14:58
our members and communities.
15:00
Promise has teams that are out in,
15:03
in the community. We are at community events.
15:06
We're on college campuses,
15:09
at low income housing complexes,
15:11
and other community places conducting outreach and offering
15:14
enrollment
15:15
and renewal assistance,
15:17
wherever we can.
15:19
We've got our provider engagement team who visits
15:22
providers
15:23
nearly every day, offering them information,
15:26
training,
15:27
and resources to help their patients navigate the
15:30
medical enrollment and renewal processes.
15:33
And,
15:34
we we are making sure that at every
15:36
touch point a member has with Blue Shield
15:39
Promise,
15:40
they are being reminded to update their contact
15:43
information,
15:44
recertify,
15:45
and reach out to us for help with
15:48
the medical renewal process. We understand it can
15:50
be challenging and frustrating,
15:53
but we are here to help them and
15:54
support
15:55
them. And, Jen, let me you know, you
15:57
you said something really,
15:59
really interesting
16:00
at the start of your your last answer
16:02
there about how more people are gonna be
16:04
losing coverage because of administrative issues and not
16:07
because they're actually ineligible
16:09
for Medicaid, which is really unfortunate. And I
16:12
I I wonder
16:14
from from the human and from the emotional
16:16
perspective of all of this, what are you
16:18
hearing on the ground level from your members,
16:21
in terms of their understanding of what's going
16:24
on, how coverage needs to be maintained.
16:27
Maybe they be are gonna be become ineligible.
16:30
What what are you hearing, from members directly
16:33
about all of this?
16:35
Well, I think we can all agree that
16:36
health care is already complicated,
16:39
and these recent policy changes are adding yet
16:42
another layer of complexity for patients and families.
16:46
Our members, providers, and community partners have expressed
16:50
concerns
16:51
and are worried about
16:54
understanding the different rule changes
16:56
and,
16:58
potentially losing their coverage over a paperwork mishap
17:02
as opposed to eligibility.
17:05
And they're also concerned about potential disruptions in
17:07
care.
17:09
And for our members who face barriers, these
17:12
changes make an already complicated system feel even
17:15
harder to navigate.
17:17
And that's why we are focused on reaching
17:19
our members where they are, helping them understand
17:22
what's changing, and providing them with hands on
17:25
support so they can keep their medical coverage.
17:28
And, Jen, let me let me also touch
17:30
on you know, as as we mentioned at
17:32
the start of the conversation today,
17:34
you're interim VP of duals program integration at
17:37
at the Promise Health Plan as well.
17:39
How are you approaching your role to best
17:41
integrate Medicare and Medi Cal offerings right now?
17:44
Does that fit into what we're talking about,
17:47
with HR one? And and do you have
17:48
any best possible approaches you'd share in terms
17:51
of coordination,
17:52
accessibility,
17:54
more affordable
17:55
offerings overall?
17:57
Yeah. So our approach is ultimately to create
18:00
an environment where coordination,
18:02
access, and affordability
18:04
are sustainable
18:05
and practical for dual eligible members.
18:08
And we are working to ensure,
18:10
that Medicare and Medi Cal
18:13
is seamless
18:14
for our members and providers.
18:16
And we're really focused on streamlining
18:19
our operations and workflows
18:21
so teams are working together
18:23
and providing unified support.
18:26
We're making coverage easier to understand and access
18:29
with clear communication
18:32
and a no wrong door approach
18:34
to servicing every one of our members.
18:38
We are looking at reducing out of pocket
18:40
costs,
18:42
aligning payments, and ensuring members stay covered through
18:46
their life changes.
18:48
Looking at supporting clear, consistent rules at state
18:51
and federal levels
18:53
to simplify enrollment and keep coverage. So really
18:56
looking to strengthen policy advocacy
18:59
and,
19:00
and making sure that we've got support in
19:02
that in that area as well.
19:05
Wonderful. Well well, Jen, before we go today,
19:07
you've got a lot of other colleagues from
19:09
around the country listening and facing similar challenges,
19:13
trying to figure out and navigating
19:15
all these same policy changes.
19:17
What else would you share with them, or
19:19
is there any bits of advice you'd offer,
19:21
as you as you navigate similarly?
19:24
Yeah. So I I would close,
19:27
just with a couple final thoughts. First,
19:29
for individuals who live in California, one of
19:32
the best ways to stay informed about the
19:35
Medi Cal program changes
19:37
is through the Department of Health Care Services
19:39
coverage
19:40
ambassador program.
19:42
And the coverage ambassador program was launched
19:45
at the end of the COVID nineteen public
19:48
health emergency to help Medi Cal members
19:51
understand,
19:52
enroll, and keep their Medi Cal coverage.
19:55
And anyone can become a coverage ambassador.
19:58
There is no cost or certification requirement,
20:01
and the program is voluntary and unpaid. So
20:04
you can sign up to to be a
20:05
coverage ambassador at the DHCS website.
20:09
And once you enroll, you will receive updates,
20:11
toolkits, and outreach materials
20:14
to help you and others stay informed about
20:17
Medi Cal renewals and policy changes.
20:19
So you don't have to be a member.
20:21
You can be a community partner. You can
20:24
be a provider.
20:25
You could be a member. But anybody, any
20:27
health plan representative that wants to stay up
20:30
to speed,
20:31
that's
20:33
in California, that is the best way to
20:35
stay current
20:37
with what's happening with all of the changes.
20:39
Second, if you haven't already, I'd encourage you
20:42
to connect with community organizations that are serving
20:45
your members.
20:46
Identify those community leaders who are trusted messengers,
20:50
and work with your provider network to outreach
20:53
to members early and often about the changes
20:55
in the Medicaid program.
20:57
And if you have the resources,
21:00
invest in high touch support services through navigators
21:04
and community health workers, technology solutions,
21:08
and multilingual
21:09
communications channels
21:11
to engage members. It really shouldn't be in
21:14
in either or. You know, in an ideal
21:17
state, it should be a complimentary approach
21:20
and not a trade off.
21:22
And finally, I would just remind us all
21:25
that we've navigated
21:26
hard moments in Medicaid before,
21:29
and our resilience,
21:31
ingenuity, and dedication
21:33
to the people we serve carries us forward.
21:35
Medicaid is complex and challenging,
21:38
but this work is in our DNA, and
21:40
we rise to the challenge every time.
21:43
Wonderful. I think that's a great last place
21:46
to leave things. So, Jen, I wanna thank
21:48
you for taking the time to be with
21:49
us here on the podcast and for sharing
21:51
your insights with our listeners. We really appreciate
21:54
it.
21:55
Absolutely. Thanks again for having me.
21:57
Anytime. And and to our listeners, if you'd
21:59
like to listen to more podcasts from Becker's
22:01
HealthCare, you can visit beckershospitalreview.com.