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Managed Care Plans as Critical Partners in Implementing New Medicaid Program Requirements
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Jamie Ostroff, Chief Legal Officer, California Medical Association, speaks with Kinda Serafi, Partner, Manatt Health, and Jarrod McNaughton, Chief Executive Officer, Inland Empire Health Plan, about the role Medicaid managed care plans are playing in supporting new Medicaid program requirements under the One Big Beautiful Bill Act. They focus on work reporting requirements; renewals and redeterminations; tracking cost-sharing; and provider oversight of fraud, waste, and abuse. Kinda co-wrote an article for Health Law Weekly about this topic. From AHLA’s Payers, Plans, and Managed Care Practice Group.
Watch this episode: https://www.youtube.com/watch?v=habDieBPK9E
Read Kinda’s Health Law Weekly article: https://www.americanhealthlaw.org/content-library/health-law-weekly/article/fdc58e80-1f6e-4b0b-9321-22fc6fca8764/Managed-Care-Plans-as-Critical-Partners-in-Impleme
Learn more about AHLA’s Payers, Plans, and Managed Care Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/payers-plans-and-managed-care
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SPEAKER_01Well, I want to welcome everyone. Today we're going to be uh speaking about an article uh managed care plans and uh as critical partners in implementing the new Medicaid program requirements. Uh it's an article that was uh co-authored by one of our guests, Kinda Sarafi of Manat Health, uh, along with her colleague Ellen Monts, managing director at Manette Health. Um, I am Jamie Ostroff. Uh I am a vice chair of the Pairs Plans and Managed Care Practice Group. Um, again, I like I said, I'm joined by Kinda Sarafi. Uh Kinda is a partner in Manette Health, where she leverages her extensive experience in healthcare law and policy to advise a diverse array of clients, including states, foundations, managed care plans, providers, and technology companies. Kinda is recognized as a subject matter authority on Medicaid and chip eligibility and enrollment and in designing and implementing innovative Medicaid initiatives and service delivery models. Welcome, Kinda.
SPEAKER_02Thank you.
SPEAKER_01We're also joined by Jared McNaughton. Jared is the Chief Executive Officer of Inland Empire Health Plan, also known as IEHP. In his role, he works collaboratively with the IEHP governing board to set this strategic vision and provide executive leadership for one of the five largest Medicaid health plans and the largest not-for-profit Medicaid Medicare public health plan in the U.S. He cultivates IEHP's strong partnership with providers, hospitals, and hundreds of community partners to deliver quality whole person care to more than 1.4 million members. Jared currently serves as board chair of Manifest Medics, the largest health information exchange in California. He's also a board member of Local Health Plans of California. Welcome, Jared.
SPEAKER_03Thanks so much, Jamie. Great to be with you guys.
SPEAKER_01So again, as I mentioned, I'm Jamie Ostroff. In addition to serving as a vice chair on the Pair Plans and Managed Care Practice Group, I am the Chief Legal Officer and General Counsel for the California Medical Association. I lead the CMA in defending the rights of physicians in courts, the legislature, and before regulatory agencies. And the topic of today's discussion is, as I mentioned earlier, managed care plans as critical partners in implementing the new Medicaid program requirements that we find in the one big, beautiful bill that we'll refer to throughout the podcast today as OB3. Now, of course, OB3 is vast and its breadth is well beyond the scope of today's discussion. So we're going to focus on four specific factors or requirements, if you will, under OB3. Those are the work reporting requirements, the renewals and redeterminations, tracking cost sharing, and providing uh provider oversight of fraud, waste, and abuse. So turning first to the uh work reporting requirements, um, Kinda, I'm gonna ask you if you could help us by briefly explaining how OB3 has changed the work and community engagement requirements for eligibility under Medicaid.
SPEAKER_02Sure. Happy to. So right now, um if someone is applying for Medicaid, there are a standard set of rules that every state has to apply to determine if someone is eligible for coverage. So they have to see if a person meets income requirements, if they're the resident of a state, if they meet the citizenship or immigration requirements, and individuals provide this information in an application or a renewal form, and then the state does all this stuff in the back end to see if the person is eligible, and then the person gets health coverage. Um, under OB3, that whole construct gets uh very subverted. So what happens, and this won't apply for everybody, this isn't going to apply for aged people who are over 65. This doesn't apply for children, doesn't apply to pregnant people, but for the vast majority of enrollees who are receiving Medicaid coverage, if they're 19 to 64, they're an adult, they are now not only going to have to provide information about their income, their citizenship immigration, their residency, but they're gonna have to show that they are meeting work requirements. And those are, for example, I'm working 80 hours a month, I am volunteering 80 hours a month, I'm in a work program 80 hours a month. It looks a lot like what SNAP food stamps programs apply for uh require now for eligibility. And then individuals, um, not everybody has to meet these 80-hour a month requirements. You could be exempt. So individuals um, such as someone who is medically frail, that is someone who might have a substance use disorder or a disabling mental disorder, that um Congress has really explicitly said, look, we do not expect that these individuals should have to demonstrate work requirements, meeting work requirements. So there's a sort of whole host of exemptions that also apply. I think the issue that we are the most concerned about related to OB3 is that this is a largely administrative hurdle that individuals are going to have to go through based on other states' experiences with rolling out work requirements. So, for example, Georgia and in the past Arkansas, what we have learned is that eligible individuals just were not able to get through the administrative hurdle of A, understanding what's being asked of them, and B, providing enough information for the state to be able to confirm that they're meeting those requirements. So the estimates are that 5.3 million people across the country could potentially lose coverage. These are the Office of Management budget estimates. And those are the estimates that we think are eligible people, but simply couldn't hit that sort of new set of requirements that are being put upon them.
SPEAKER_01Okay. Well, Jared, um, turning to your role at IHP, how are you preparing for these changes?
SPEAKER_03Yeah, thanks, Jamie, and huge thanks to be with you and Kenda and her great article that just outlines so much of the work that needs to happen too. So thank you, Kenda, for that. You know, at IHP, uh, we serve uh San Bernardino and Riverside counties in Southern California. We're very fortunate uh to have an incredible relationship with our two counties on data sharing agreements. Uh, that first step for us that we took several years ago has been a huge help for us that includes demographic data and monthly Medi-Cal redetermination and even pre-disenrollment files for us to reach out to those members who are currently just coming up for the redetermination or eligibility process and really allows us to provide one-on-one renewal assistance. We also have a provider network of almost 10,000 providers and have created a provider toolkit for those physicians and other providers, and even an online provider portal system that a provider can go in and actually run their roster of who they're going to see for that week in their practice against our data that we have received from the counties to understand which of their patients are going to be coming up for renewal in the next 60 days. And all of that kind of work, along with leveraging relationships with community-based organizations, to make, of course, in the future service opportunities available because part of this work requirements is there's also a community service opportunity there that folks can get connected in with CBOs or community-based organizations, just to make sure that everybody throughout the continuum of care for a member is connected in with resources to help those members or their patients stay on Medi-Cal if it's appropriate. And we really want to make sure that that data flow that's going to our providers, uh, because they're the ones that see them most regularly, that they have the opportunity to really step in to support them as much as possible.
SPEAKER_02Oh, Jamie, I was just gonna I was gonna layer on. I think you know, what Jared describes is a best in class. You know, this to me is this best practice infrastructure where the state gives the plan, that monthly roster of information, and then IEHP is really committed. They have a very vested interest in going out and helping people and then having their providers help people. I think it's important to note that this is a bit of an outlier. I mean, there's a lot of plans across the country that are definitely working closely with their states, but we're just not at a place where it's standardized the way that Jared was describing it. And I think there's real opportunity now. Um, what I didn't say at the front end is this is all going into effect in January of 2027. So time is of the essence. Um, so states are trying to work pretty fast and furious to set up that data sharing infrastructure and get contract amendments with their plans. And then the plans, if they don't, if they're not like IHP that have already been doing this historically, this is a new process, right? They're gonna have to kind of build within their infrastructure this monthly cadence of, hey, Joe Smith, you are up for renewal and then there are new changes here. And not only do you have to submit information on your income and submit the renewal form, but you're now gonna have to show all these other compliance activities, and we're really there to help. So I think um I'm really happy we're having this podcast because I really hope that states and plans that have not yet gotten to be as far as IEHP will really start moving on it.
SPEAKER_01Well, I think we're gonna get a bit of a preview on this. Uh, I think Nebraska uh kind of got out there early on this and and implemented uh their work requirements as of the first of this month. And I I recently read that with respect to the medical frailty exception, the state published a 295-page list of applicable conditions. And now the the plans, like Jared's, are going to have to sift through those those conditions and line them up with their um the data that they have on their existing members or potentially new enrollees to determine whether or not they meet those eligibility or the the exception requirements or exception eligibility.
SPEAKER_02Well, you know, I think it's a great point. And you're you're absolutely right, Jamie. I think states as a first line of defense are looking at their own claims and encounters system that plans submit to states. So provide so in a managed care state, um the plans sort of aggregate the claims from their providers and then submit them as encounters. And that's what states are going to be sifting and sorting through that data out that they have within their own state warehouses. But they may ask, and you're raising a really good point, for plans to do more, which is then also identify. I think that, Jared, I would love to know if that's something that your plan is thinking of doing, because I think that's the next, that's a harder lift than the outreach. But I would love to hear if that's something that you're thinking about as well.
SPEAKER_03Yeah, Kenda. In fact, uh, our team was just chatting about a recent meeting that we had with our State Department of Healthcare Services on this issue, uh, where it appears, Jamie, to your point, that uh Nebraska being the one of the first out of the gate on this, at least our state here in California, right now, is putting a list together of that medical frailty framework that our CMO, our chief medical officer at IHP is actually part of that process team, that task force that's working on that. And the key from what we've heard from the state so far is that they're going to allow, it looks like potentially, an attestation to be signed by a provider based on those couple of hundred different codes that the state currently is looking at. But to your point, Jamie, the key to that is that later on, that encounter data that Kenda talked about actually has to match what the attestation said. And so thankfully, in our case, it appears that that data flow that's coming through one of our incredible partners on the health information exchange side, that Manifest Medics, that the state will eventually allow those qualified health information organizations throughout the state, because there are multiple ones, to be a part of the solution to that problem, to make sure that all of that encounter and claim information is actually matching to that medical attestation. So that's a very important piece to this puzzle because it will allow folks to have a little bit of grace time, if you will, for providers to work with their patients to get some of that uh documentation completed. But then the proof has to be in the actual data later on. And that's going to be something that we're all going to have to really work closely with. And those MOUs, those memorandums of understanding for data sharing are absolutely critical to make that happen, either with your counties and with uh health information exchange.
SPEAKER_01Yeah, thanks. Thanks, Jared. That's actually it's a great point. Um, well, I I think we'll move on to the next topic. Um uh renewals and redeterminations under OB3. Um, Jared, how did the the recent COVID return redetermination requirements prior to the passage of OB3 impact your your enrollment at IHP?
SPEAKER_03You know, it's kind of been a wild ride, uh Jamie, to be honest with you, because we had the COVID situation happen where for us at our organization, we had a peak of about 1.7 million members within our two counties. Uh, with that PHE or public health emergency ending, uh, we actually saw a drop down to about 1.5 million members or so uh over that period of about 2023, ended in 2025 of July when the PHE and winding kind of actually ended from what the feds allowed the states to do. So that delta there was pretty dramatic, about 200,000 members. And we're actually forecasting that we're going to lose another 300,000 members by the end of we think around 2027, based on both the OB3 issues on the federal government side as well as our own state issues that we have within California of how redetermination eligibility is changing over time. So we're talking about a vast amount of people in our case, going from that all-time high of 1.7 million members down to about 1.2 over the next 18 months or so. That's a lot of folks. That uh to Kenda's point, and I know she even talked about this in her article, that that I mean, we're talking about a massive amount of people in our country uh that will not be covered and the strain that it's going to have on the healthcare system as a whole.
SPEAKER_01Well, well, Kinda, turning that to the OB3 requirements, how how are they different from the redeterminations under the at the end of the COVID pandemic?
SPEAKER_02Yeah. So when, you know, during COVID, the federal government paused all renewals because there was a public health imperative that people have their health insurance. And it made no sense to kind of keep going through the renewal process when we knew people would tend to lose coverage. They experience churn. They um lose coverage because they didn't follow up with a renewal form, they go out to see the doctor, get their medication prescription filled, they realize their insurance is left, they go back, they re-enroll, they've been eligible all along. It was just a paper problem. That at the moment during the time that that Jared was talking about, where he um had at his peak and then it began to unwind, was what we thought was the worst thing that could have happened when it came to Medicaid coverage. And now we didn't even, we couldn't conceive that it could get worse, quite frankly. It's it's the unwind on steroids with these new requirements and and what the OB3 expects of individuals is that they have to renew every six months. So no longer am I applying in January and then I have my coverage until December of the fall of 12 months later. But now I'm on a January to July cycle. Every six months I am going through the process. That is going to have a lot of damage. It's going states are across the country uh really feeling really anxious. They don't have the eligibility enrollment workforce to respond to the capacity needs of the of that process. Um their call centers are not ready and equipped to be able to handle the questions about the six-month renewals. And individuals, just like what Jerry kind of very clearly illustrated that drop, that's the drop that we're gonna see just because individuals may have moved and not provided updated information or don't understand what's being required of them. At the same time that they're doing six-month renewals, they're also reporting on their work requirements. So it's a real administrative um issue. And I think what we're gonna see is the numbers that Jared has described across the country and plans are gonna get hit. I mean, there's their numbers, their enrollment numbers are gonna be considerably lowered because of this administrative process.
SPEAKER_01Well, and Jared, given given that impact on or potential impact on enrollment, um how are you at IEHP adjusting to account for these uh biannual or semi-annual, more accurately, uh redeterminations?
SPEAKER_03Yeah, you know, it's interesting uh what what Kenda was sharing because uh folks that have never been through uh eligibility or redetermination process, uh, for those that have never been through that, it's actually similar to filing your taxes. I mean, that's the kind of rigor uh that's placed on this. And so to your point, Jamie, this is not some easy one-page thing that you get to sign off and you're done. Uh, it's it's incredibly rigorous. Uh, and so our biggest concern uh really on this is exactly what Kenda shared is actually the stress on the counties. In California, the counties are responsible for the redetermination and eligibility process. Already with the PHE or the public health emergency unwinding that we spoke about, the counties were way behind. I mean, the backlog was just huge. And it's not for them not trying, they're doing their very best that they possibly can. But with this all-new bolus of membership that's going to have to go through that every six-month requirement for redetermination, our biggest fear is that there are going to be so many tens of thousands of people that will literally just fall through the cracks because there is simply not enough people in the county redetermination and eligibility teams to actually process uh this work. And we've started to see that already with that PHE unwinding. And this is gonna just be, I think, a catastrophic issue for our community. I think you're gonna see a lot more people come into hospitals. The hospitals are gonna have to be the ones to place them on emergency medical, you're gonna, you're gonna or Medicaid across the country. You're gonna start to see a lot of those kinds of processes having to fill the gaps. Administrative burden and cost is gonna just go way up for our provider community. Uh, and you're gonna see a tremendous amount of uninsured uh folks coming into hospitals and providers because of this issue. So for us, the the big concern with OB3 is it feels like uh that it's an administrative burden to decrease membership, and it really has nothing to do with whether or not a person should or should not be on the Medicaid program. That that's concerning from a policy issue because in our country, uh, we believe that it should be appropriate for folks to be on the program of Medicaid if they fully qualify and not throw up administrative burdens in the way for people that are just barely making it as it is. And this kind of process has to be in place to try to actually shift as many people out of the program as possible, in our opinion.
SPEAKER_01Well, and and and not only is it placing the administrative burden on the enrollees, but it's also placing a considerable amount of administrative burden on the system that is already incredibly strained under, you know, under current circumstances. So a lot, a lot of a lot of work there. And again, I think it's gonna require a considerable amount of coordination across the system that again, I'm not, you know, at least at this stage, confident that the system can handle. Um, well, uh let's let's turn to the the tracking of cost sharing. Um uh a little bit of a uh I think at least to me a complicated issue, but I might maybe Kenda you can help us break it down and understand the the requirement under OB3.
SPEAKER_02Sure, sure. So historically, states have been allowed to apply copayments to non exempt services for populations that are not exempt. So for example, you can't have copays for pregnant people or for children, but um you can apply this co-pays, for example, on medications or for non emergency use of the emergency room, or for other services like dental services or optometry. Um and States have historically used copayments as a structure and a mechanism, giving them themselves the option. In this under OB3, the federal law requires that states must, not may, but they now must apply a copayment. And it must be more than zero and up to $35. And it has to be for adults who have incomes above 100% of the federal poverty level. So these are low-income individuals who are those expansion adults who are also subject to work requirements and they're also subject to the six-month remote. The the historic issue around co-payments is there's this underlying requirement that says states may not um apply co-pays that exceed 5% of their aggregate income, their aggregate household income. So what that means is that if I incur a copay and then I incur multiple co-pays, let's say I'm on multiple medications, that uh co-pay total that I'm paying, either on a monthly amount or on a quarterly basis, can't exceed 5% of my income. And I tell you that because that has surprisingly been a very difficult thing for states to operationalize. The reason why is because co-pays are related to service utilizations and that information lives in one side of the state system that claims an encounter system. And then eligibility and enrollment, what the household income is, lives in the eligibility system. And those two systems don't talk to each other. So states have usually thrown their head hands up in the air and are like, I can't do this. And oftentimes that's the reason why they don't even apply co-pays because the infrastructure for tracking is just too hard. Not to mention the fact that co-pays are historically research has shown they they they end up being barriers uh to access to care. So my long way of saying that states are looking for ways to solution this co-payment tracking. And states are looking to their plans as a way. I was actually just talking to a state last week, and they were like, we won't be able to do this, and we hope our plans will. So they're basically going to be delegating a lot, not all, but many will look to their plans to try to figure out what they have not been able to figure out from a co-payment tracking perspective.
SPEAKER_01Okay. Well, I again, uh, you know, picking up on the this recurring theme of pushing administrative burdens onto the plans, uh, Jared, what kind of challenges could do you anticipate that this uh that this new requirement is going to place on IHP?
SPEAKER_03Yeah, I I think Kenda just hit the nail on the head. I mean, it's it is an incredible shift in our state uh here in California with this requirement. And the big concern that we have is, of course, the the coordination among providers and the counties and the state and the health plans. That that's one piece of this. But our real worry in our case is that in many times it's gonna be up to the provider to ensure that they collect the appropriate cost sharing amount from the member. And that means that it's gonna be an additional administrative burden for the provider side as well, that they have to account for. And so we're really anxious to hear more details on this from our state on how they're gonna implement cost sharing for various services, like set dollar amounts or percentages of the Medi-Cal rate, and how how does all of that work and what will that exactly look like? Uh, we have a lot yet on this particular issue in California to really understand from the state guidance on this. But to your point, Jamie, again, the the biggest issue for us is that we're throwing up another burden, an obstacle in the way of folks that, as Kenda shared, they are just right over the poverty line for the federal poverty limit, which is incredibly low, uh, by the way, uh, that threshold. And you're just throwing up obstacle after obstacle in the way of people that already are so incredibly burdensome and many, many times are doing the very best that they can to support their families. And so, more to come on this from the California perspective, we're still waiting for that guidance, but we're really concerned about the additional administrative burden, particularly for the provider community.
SPEAKER_02Yeah, I mean, we're talking about people who make $17,000 to $20,000 a year for a household of one. This is, these are not people who have disposable income and are facing a real affordability challenges already.
SPEAKER_01And now you could you're you think about adding copays to Yeah, I think the way that this is characterized is is somewhat deceiving to someone who hears 100% of anything, they think that is going to be a large number. But you're this is a a 100% of a very, very small number. That's right. That's right. Well, turning to our final topic under OB3, um, Jared, uh there's evidence that providers, and we're gonna talk a bit of this about fraud, waste, and abuse in the system, and we've heard a lot about that from the from the administration. Um there's evidence that providers are a source of most of the fraud, waste, and abuse in Medicaid. I'm not sure I agree with that, but that's what the evidence shows. Um, but is that consistent with your experience?
SPEAKER_03Yeah, it's a very interesting uh question, Jamie. You know, I uh my my all of our parents, my wife's parents and my parents uh are all on uh Straight Medicare with a supplemental. And uh we have been shipped uh so many um supplies from DME providers, uh durable medical equipment for us from across the country that they never ordered. Uh and so I I have gone into the OIG system and then reported these folks over and over again. Now, mind you, this is straight Medicare. So this is from the federal government. Uh, this is not a plan, this is not a Medicare Advantage plan, this is not a health plan like us that are doing a lot of these shenanigans. And it's also not physicians. Uh, and that's something important to point out. In our case, what we see in our, at least in our region within the two-county region, many, many times the kinds of things that our system flags, because we have actually have a complete fraud, waste, and abuse system that lays on top of our claim system that helps our team identify strange anomalies that then we have a human go into and actually do a deep dive in. Uh, much, I would say 99% of these are actually not physicians. Uh, they're actually other entities out there uh that are part of whether it's a Callean program in California that adds on to in lieu of services for our state or all the way through to other providers in the system that we have found potential fraud, waste, and abuse in. I'm very proud that IHP, according to the state of California, actually reports more potential fraud waste or abuse than all the other health plans in California combined. We take this very seriously. Now, whether all of that is actual fraud, waste, and abuse, you have to go through the investigative process to figure that out. There could be a lot of reasons for different claims that might pop up, or if you see anomalies and usage that pop up. But even something that was a very hot topic, Jamie, as you know, the hospice program uh right now, uh hospice is a very hot topic across the country. Thankfully, our team about three and a half years ago started on a journey of uh what we call the quality hospice network, where at the time we had 700 hospices, uh, three and a half, four years ago, actually part of sending claims to us. We've narrowed that down to 30, a little over 30 now. And we did that all based on quality data that they are have to actually submit to us. And so I'm so grateful. This was long before the feds ever got onto this topic, uh, that our team said, you know what, let's create a quality hospice program. Anybody can be part of this, part of that program, but here are the stipulations. You have to report your quality data to us, you have to report it to the state of California, you have to be open to joint operating meetings where we actually meet with you in person to understand what's going on and do chart reviews together. That is an incredible feat in my mind of what a health plan can and should be doing to protect all of the other providers who, again, the vast majority are doing phenomenally incredible work to protect them from some of those shenanigans providers that are out there.
SPEAKER_01Well, yeah, it sounds like you have a very robust system in place already to address these kinds of issues, Jared.
SPEAKER_03Um, you know, there's there's always learnings every day. Sure. Learnings every single day, but we feel like those little incremental steps uh and do it in conjunction with providers so that they're part of designing that work uh is really important to us.
SPEAKER_01Great. Well, well, Kinda, given given this heightened area of focus for the states, you know what types of new requirements or expectations do you think this the states will be placing on MCOs in this area?
SPEAKER_02Yeah, I think um I think it'll be a lot of what Jared is describing his plan does just as sort of the course of business. Um, but we'll probably see more formalized contract amendment language and expectations for it. States are certainly um paying a lot of attention. They've always paid a lot of attention to Fraudways interviews. There's a overall overwhelming commitment to rooting it out, both um on the eligibility for the individual, but and as well as the provider. Um, but what we'll probably see is maybe more stringent requirements that the plans use advanced analytics to, and you know, this is a great use case for AI. I think we can sort of all agree on this for detecting billing anomalies, as Jared was talking about, outlier utilization of um of services and billing, upcoding, duplicate billing, services that seem inconsistent with provider licensing. This is all you the plans have such rich data that now there is a real opportunity to use that and help be partners and work shoulder to shoulder with state Medicaid agencies and try to provide information where it seems very clear that investigations could be could be needed. I think Sherry makes a good point. Like just because you see something in your data doesn't mean it equals fraud, but it does mean it's worth it for us to take a second look. And I think there's a real opportunity for plans to to work with states on on with in that effort.
SPEAKER_01Well, yeah, uh certainly a lot to come on this, on these, on these topics we've covered today. Um I want to thank you both again, Kinda from Manat Health, Jared McNaughton, CEO of IEHP Lenpire Health Plan in California. Again, the article that uh this this was based upon is Managed Care Plans as Critical Partners in Implementing New Medicaid Program Requirements, authored by Kinda and her colleague Ellen Monts. And thank you both.
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