Latest / Becker’s Healthcare Podcast / Preparing for Medicaid Eligibility Changes Under the One Big Beautiful Bill Act

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Preparing for Medicaid Eligibility Changes Under the One Big Beautiful Bill Act · Becker’s Healthcare Podcast

• 0:00
  Hi, everyone. This is Brian Zimmerman with Becker's
• 0:02
  Healthcare. Thank you so much for tuning into
• 0:04
  the Becker's Healthcare podcast.
• 0:06
  Today, we're going to talk about preparing for
• 0:08
  Medicaid eligibility changes under the one big beautiful
• 0:12
  bill act.
• 0:13
  Joining me for today's discussion is Chad Wallace,
• 0:16
  president of eligibility services division at MedMetrix.
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  Chad, thank you for being here.
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  Thank you for having me. It's a pleasure
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  to be here.
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  Chad, great to have you on. And and
• 0:27
  and before we get into our conversation
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  today, why don't you give listeners just a
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  quick sense of your of your background and
• 0:32
  the work you're doing now?
• 0:34
  Sure. Thank you. Currently, I'm the president of
• 0:37
  the eligibility services division of MedMetrix.
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  I'm responsible
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  for overseeing the operations of all of our
• 0:43
  entitlement programs.
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  I have twenty five years experience in health
• 0:47
  care,
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  eighteen years of which have been directly involved
• 0:50
  in Medicaid.
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  I have a lot of experience with professional
• 0:54
  organizations in providing,
• 0:56
  talks and and information,
• 0:58
  educational sessions for for lots of groups. And
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  I participate in a lot of state and
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  federal stakeholder meetings related directly,
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  to Medicaid policy.
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  Excellent. Well, you're a great person to have
• 1:11
  on for for this topic.
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  Let's dive in here. And, of course, the
• 1:15
  one big beautiful bill act has a lot
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  of moving parts,
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  but December 31, not not for New Year's
• 1:20
  Eve parties, but it should be on everyone's
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  hospital leaders' radar.
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  For leaders that haven't had time to sort
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  of dig into the details here, what are
• 1:28
  the provisions that will have the most immediate
• 1:30
  and significant impact on Medicaid eligibility
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  and hospital revenue, of course? Chad, can you
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  unpack that for a little bit? I know
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  it's a big question, but hoping to get
• 1:39
  some some some sound advice out there for
• 1:41
  folks.
• 1:42
  Yeah. It's a great question. And there's a
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  lot, as you said, in this bill.
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  And when you think about what are the
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  most important aspects of it, I think I
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  would narrow it it down into two areas
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  from a revenue cycle perspective, and that's
• 1:56
  eligibility and enrollment reforms.
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  And in those particular areas, there are two
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  items that are most important,
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  which are
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  redeterminations
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  for the Medicaid expansion population or adult expansion
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  population at six months
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  and community engagement and work requirements that will
• 2:14
  be needed for that population as well.
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  In addition to that, you know, revenue cycle
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  leaders should be taking into consideration
• 2:22
  the larger picture too with this bill.
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  There are big pieces into this that affect
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  not just revenue cycle, but
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  high finance and funding aspects of the bill.
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  And what that will do is translate into
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  downward pressure on margins and operational costs through
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  reductions in provider taxes
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  and state directed payments.
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  The combination of those two elements of Medicaid
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  enrollment
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  and engagement
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  and and the funding cuts are gonna also
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  create
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  an additional concern that everyone should be aware
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  of and thinking about, which is its effect
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  on DISH and three forty b programs.
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  With the reduction
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  of the number of individuals across the country
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  that will have Medicaid coverage,
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  the available market of Medicaid days
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  for treatment and the disproportionate share
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  formula
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  of DISH
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  is going to be decreased, which will put
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  the potential for risk of several facilities, many
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  facilities of receiving DISH payments.
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  Even more important to that DISH payment
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  is the effect it could cause on their
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  ability to reach the three forty b drug
• 3:32
  discount program, which has significantly
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  higher revenue implications
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  than even the DISH side of things.
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  Yeah. That that's a big one. Right? I
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  mean I mean, three forty b specifically too
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  for some organizations in certain parts of of
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  the country, that that's crucial for them. Correct?
• 3:50
  Absolutely. And particularly in rural health hospitals from
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  that standpoint. You know?
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  Discount drug three forty b programs is a
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  is a take it you you're either in
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  it or you're out of it. Right? You
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  get to 11.75
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  in dish payments, and you get into the
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  the the discount drug three forty b program,
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  which offers and affords health systems
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  tens of millions of dollars in reimbursement.
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  Right?
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  It it doesn't matter what you get above
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  11.75.
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  You just have to get there. And if
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  you get there, you get into that program.
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  DISH, on the other hand, is a is
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  a situation where you can increase the number
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  of days in your your additional supplemental payments
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  can increase, but not nearly as much
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  as the, differential between what the drug discount
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  programs will be. I think that is really
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  a a hidden
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  area in this bill that's exposure to
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  health care facilities from a finance standpoint
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  is
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  the large effect that could take place in
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  losing three forty b drug discount programs
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  simply because of the fact that you're unable
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  to treat the number of Medicaid patients that
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  you have in the past to be able
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  to reach
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  that dish formula.
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  So, Chad, it it might be
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  I I guess you could characterize
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  hospital responses here historically to to policy changes
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  like this to to Medicaid as being traditionally
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  reactive,
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  which causes some scrambling to to really adjust
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  and and get staffing right, workflows right,
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  on the fly here. But given how much
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  is really going on here and how significant
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  the implications are,
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  what does it look like for health system
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  to be proactive
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  important steps folks should be taking right now
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  to prepare?
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  Yes. It's a great question, and I think,
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  I could add a couple of thoughts to
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  that. First of all, I'm sure most health
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  systems are running their own, stress tests on
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  their systems on what they think their reductions
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  in Medicaid reimbursements will be, and that's very
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  important
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  to look at and take. But in the
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  areas of enrollment and eligibility,
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  health systems really need to be taking this
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  time to focus on improving
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  their technology in the areas of,
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  helping and assisting patients with Medicaid enrollment and
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  retention of their Medicaid services
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  and also
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  investing in technology
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  to
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  provide
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  automatic renewal notices and reminders via their EHR
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  to when patients are gonna need to be
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  redetermined.
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  Right? We're going through a period
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  where patients that are that are approved under
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  the Medicaid expansion population,
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  those are individuals that are aged 19 to
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  64, typically single working adults,
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  and that population
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  is really at risk in terms of,
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  losing coverage. That's the population that will need
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  to be redetermined every six months. That's the
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  population that will need to demonstrate eighty hours
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  a month of work or community service engagements,
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  and and it's a big focus.
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  So the things you can do to help
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  those patient populations
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  is
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  meeting them where they're at to assist them
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  in getting the redeterminations
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  and their enrollments
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  done on time,
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  creating
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  alerts in your
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  EHRs to identify when patients are gonna be
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  coming up for a renewal and reaching out
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  to those patients
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  ninety days, sixty days prior to when that
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  happens so you can get that process started
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  and and prevent that loss of coverage.
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  Also, partnering with with community organizations
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  and other outside groups so that you can
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  channel individuals
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  that need to meet work requirements
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  to air to organizations that can help them
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  do that. Right? So if you partner with
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  other with community organizations that provide,
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  you know, volunteer work or things that individuals
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  can do to meet those requirements, and you
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  could help direct patients to those to those
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  locations to meet those requirements,
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  it would help to go a long way.
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  In in addition to that, though, there is
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  a large concern around the immigrant population.
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  And
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  health care leaders
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  really need to be taking consideration and putting
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  some focus around
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  the impact of immigrant populations
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  and their their finances that they're contributing to
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  their organization.
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  So, Chad, you know, eligibility
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  determination has always been labor intensive. This is
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  gonna be, you know, a challenge for folks
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  to get their arms around for sure. But
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  perhaps one, I I guess,
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  one good thing, one really positive is sort
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  of the technology that's available today, whether that's
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  automation, AI, or better data integration
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  to really help hospitals manage these changes
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  and and and help, you know, their their
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  patients, their communities as well navigate these changes.
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  So, I guess, what are you seeing from
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  from a technology perspective that can be beneficial
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  here?
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  Sure. Yeah. I mean, in in a lot
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  of ways, tech is what's the thing that's
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  gonna make health systems go from being reactive
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  to proactive like we discussed earlier.
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  But the important areas to understand from a
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  technology standpoint
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  is that the advancements
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  in AI modules
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  and learning modules has made it so that
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  AI eligibility verification is much better today than
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  it's ever been, and it's improving,
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  as we speak.
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  Healthcare leaders need to really be thinking about
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  investing in eligibility
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  verification and retention technology,
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  which is coming online now.
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  There are organizations
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  that are implementing them, bringing them into speed.
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  Additional technology
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  uses could are there for patient outreach,
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  particularly in outpatient and ED settings. Right? As
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  we talked about,
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  there is a reduction in the number of
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  individuals that will be qualified for Medicaid.
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  As a result,
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  ensuring that you get credit for treating every
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  Medicaid patient in your system is important,
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  and that now makes makes it important to
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  understand every treat and release patient that you've
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  had in the ED,
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  every outpatient
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  encounter that has that a Medicaid patient has
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  received, you need to make sure that you're
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  capturing those. Right? Those are areas that have
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  often in the past been missed. Inpatient
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  Medicaid
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  work has has traditionally been the focus, and
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  that's where most of the dollar almost all
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  of the dollars are from a reimbursement
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  standpoint.
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  And that those chain changes to the inpatient
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  side of Medicaid eligibility and enrollment
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  are gonna be helped and advanced with technology,
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  but the real,
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  benefits are gonna be seen in the outpatient
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  and ED side of things where we can
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  start to get to patients where we haven't
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  been able to get to in the past.
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  Being able to reach out to patients with
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  technology
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  using SMS technology,
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  using phone calls to get patients to pay
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  patient portholes to upload their documents themselves,
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  allowing us to use AI to reach out
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  for for insurance
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  information
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  and employment verification information.
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  Setting technologies
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  in your EHR system for reminders of when
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  patients are gonna be coming up for the
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  renewal dates are vitally important, particularly for that
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  population.
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  Having
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  technology
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  integrated into your EHR, which helps to coordinate
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  and identify and track the work requirements
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  and work engagements that are going on with
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  your patients,
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  is also important. In general,
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  tech is gonna allow you to get a
• 11:30
  larger and better understanding
• 11:32
  of your Medicaid patient population
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  and then better enable you to reach out
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  and
• 11:40
  Medicaid process as opposed to sitting back and
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  having to react to what comes in.
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  Chad, I think that was a a a
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  useful sort of sort of
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  summary there of some of the great technology
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  that's available for folks to to to really
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  help them get their arms around this situation.
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  Let's close here with sort of the a
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  big picture question, two parter.
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  These provisions are gonna land differently depending on
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  a hospital's geography, pair mix, patient population.
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  Where in in your honest take is the
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  greatest strain gonna be? And for a leader
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  that gets this this this proactive preparedness right,
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  what does success look like on the other
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  side of December 31?
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  Yeah. Sure. That's a great question. And, you
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  know, the strain is gonna be all over
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  the place. But right now, when I look
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  at things, my biggest concern
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  is
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  compensation for immigrant populations.
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  There is a lot of pressure in our
• 12:34
  society
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  about immigration policies, which are concerning for for
• 12:39
  individuals that are afraid to come in for
• 12:41
  care because they're afraid that they're gonna be
• 12:43
  turned over into immigration services and be deported.
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  What that means is
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  there are changes to how reimbursement is being
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  done for the immigrant population.
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  We're only gonna be it's gonna be strict
• 12:56
  reimbursement to emergency use only.
• 12:59
  Absolutely, we'll we'll follow guidelines,
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  but they are gonna be very strict and
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  only reimbursing
• 13:05
  for emergency care services only. No ongoing services
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  or or things along those lines, which is
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  important to understand.
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  Why that's a factor is you you have
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  the immigrant population right now that's, as we
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  said, is very concerned about
• 13:21
  coming into health care facilities to seek care.
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  Why? They're concerned that their information is gonna
• 13:25
  get turned over to immigration services, and that's
• 13:28
  gonna cause them to be deported.
• 13:30
  What that's causing is immigrant populations to not
• 13:33
  seek health care services.
• 13:35
  So individuals that may come into the emergency
• 13:37
  room with a stomachache or some type of
• 13:39
  problem, they're not showing up with a stomachache,
• 13:41
  but they are gonna show up later with
• 13:43
  severe
• 13:44
  issues and those that stomachache could turn into
• 13:47
  a perforated ulcer or stomach cancer or something
• 13:50
  much more serious. And you and if you
• 13:52
  play that out in a lot of different
• 13:54
  areas and a lot of different product or
• 13:56
  service lines,
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  you can see that
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  what's going to happen and is happening is
• 14:01
  immigrant populations are delaying care.
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  So when they do seek care, they're going
• 14:06
  to be sicker, and it's gonna be more
• 14:08
  costly to care for them. So the big
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  concern from what I stand for right now
• 14:14
  that's not necessarily being talked about, which really
• 14:16
  should be, is this immigrant population in the
• 14:19
  effects it's gonna have on our system,
• 14:21
  not just reimbursement,
• 14:24
  but the ancillary effects of preventing these patients
• 14:27
  from seeking care and then also having them
• 14:30
  be at a much higher acute level when
• 14:32
  we do need to treat them for care
• 14:34
  because we are going to have to treat
• 14:36
  them. And at the point that we will
• 14:37
  treat them, though, it'll be much more expensive.
• 14:40
  Yeah. That that higher acuity
• 14:43
  just placed a big strain on systems in
• 14:45
  terms of
• 14:46
  just what what is needed from from the
• 14:48
  workforce, what is needed from, you know, just
• 14:51
  administrating all that. Is that that correct? That
• 14:53
  that's just gonna put an added strain on
• 14:55
  everything?
• 14:56
  Yes. That's that's correct. And, you know,
• 14:59
  what I would say
• 15:00
  from a a health system looking at on
• 15:03
  the other side of this, what does success
• 15:05
  look like? Success looks like that you've had
• 15:08
  put together as a plan in place to
• 15:11
  address
• 15:11
  the major populations that are gonna be affected,
• 15:14
  which we talked about. The Medicaid expansion population
• 15:18
  and immigrant populations.
• 15:20
  Plans need to be taken right now and
• 15:22
  implemented
• 15:24
  to make sure that your organization is protected
• 15:27
  from revenue loss from those specific populations.
• 15:31
  And if success is gonna look like
• 15:34
  when we're done with this, having had
• 15:37
  done the work prior
• 15:39
  to protect those those streams and seeing yourself
• 15:42
  being able to assist patients. After we get
• 15:45
  through December 31, success is gonna look like
• 15:48
  being able to functionally proactively
• 15:51
  assist patients
• 15:52
  in getting coverage,
• 15:54
  meeting work requirements, and retaining their coverage.
• 15:57
  Yeah. Some really important points. And and, of
• 16:00
  course,
• 16:01
  it's gonna look different for for every organization.
• 16:03
  Right?
• 16:04
  Absolutely. Absolutely. Yes. And, you know, it's about
• 16:08
  taking the time now to make the plans
• 16:10
  for the future
• 16:11
  that, we do have a little bit of
• 16:13
  time before this happens,
• 16:14
  but it it needs to be addressed right
• 16:16
  now. We are gonna have some some,
• 16:19
  advantages of looking at what some states do.
• 16:22
  The requirements are taking place December 31, but
• 16:25
  there are some early adopter states.
• 16:28
  Nebraska,
• 16:29
  Montana, and Arkansas
• 16:31
  are are starting sooner than some other states.
• 16:33
  Nebraska and Montana are gonna be initiating on
• 16:36
  May 1 six month renewal processes. Work requirements
• 16:40
  won't go into a place then, but they're
• 16:41
  gonna start doing redeterminations
• 16:43
  at six months. And we can start to
• 16:45
  see and learn from how other states are
• 16:47
  doing things in the coming months to adjust
• 16:50
  how things can look like in the future.
• 16:52
  Other states like Arkansas
• 16:54
  and,
• 16:55
  Iowa will be implementing some work requirements later
• 16:58
  in in the in the year, and we'll
• 17:00
  also be able to see,
• 17:02
  and learn from some of those examples of
• 17:04
  things that take place. So those are some
• 17:06
  good positive things that we may be able
• 17:08
  to look at. There are some states that
• 17:09
  are gonna be using some early adoption of
• 17:11
  some of these programs,
• 17:13
  and we'll be able to identify and and
• 17:15
  look at that and and see what's working
• 17:17
  and what's not working.
• 17:18
  Yeah. For sure. It's it's important to to
• 17:22
  be having these conversations. And, Chad, I hope
• 17:24
  I I'm grateful for you coming on the
• 17:26
  podcast today
• 17:27
  to to spread the word. So I truly
• 17:29
  appreciate you taking the time. Well, I thank
• 17:31
  you very much. It's been a pleasure, and
• 17:32
  I and I I appreciate the opportunity to
• 17:34
  speak with you.
• 17:35
  Absolutely. Thank you, Chad.
• 17:37
  We also wanna thank our our podcast sponsor,
• 17:39
  MedMetrix.
• 17:40
  You can tune to more podcasts from Becker's
• 17:42
  Healthcare
• 17:43
  by visiting our podcast page at beckershospitalreview.com.