Navigating Medicaid Legislative Changes: Eligibility & Enrollment
NAHAM Webinar with ElevatePFS Regional President Godlee Davis
Video Transcript
NAHAM Speaker: Hello, and thank you for joining us for today’s webinar, Navigating Legislative Changes: Medicaid Eligibility and Enrollment, sponsored by Elevate Patient Financial Solutions.
NAHAM promotes best practices, standards, and subject matter expertise; provides an array of networking, education, and certification opportunities; and enables our members to influence and promote high-quality delivery of patient access services. Just a few of our numerous membership benefits include those shown on the screen and much more. Our membership is comprised of more than 2,100 patient access professionals across the country, and membership provides a unique opportunity to network with leaders in the field.
To get us started, I’d like to introduce our speaker for today, Godee Davis, Regional President of Eligibility Operations at ElevatePFS. Godlee, I’ll hand it off to you.
ElevatePFS Regional President Godlee Davis: Good afternoon, everyone. I’m very happy to be speaking with you today.
I’ll start by telling you a little bit about ElevatePFS. We have been in revenue cycle management for over 45 years, with extensive experience across our leadership team, and we employ more than 3,000 people. One of the things we’re most proud of is being a great place to work, because our employees really do make a difference, and we invest significantly in them. We’re also very proud of our client retention. We achieve that by building strong partnerships with our clients and focusing on long‑term relationships rather than short‑term results. We believe that experience and client retention, driven by great people, are what make us a best‑in‑class service provider for eligibility services.
Today, we’re going to be talking about OBBBA, as some people may refer to it, the “Big Bill,” and the impact of certain healthcare provisions, particularly how they affect Medicaid and Marketplace enrollment. After reviewing those changes, we’ll discuss some strategic options to help address the negative impacts and talk through ways to mitigate them so they are not as severe.
When we look at the bill overall, I wanted to summarize the major impacts and what we’ll realistically see as a result. We’ve narrowed this down to three key areas. First, people are going to lose coverage. This is not an unintended consequence. One of the primary goals of the healthcare provisions is to reduce Medicaid enrollment, because those savings are being used to fund other parts of the bill. When policymakers who are not directly involved in healthcare design legislation, providers often end up absorbing the consequences. Second, everything is getting harder. More verifications are required, and patients and applicants must provide additional documentation to qualify for Medicaid. There are more hurdles and hoops to jump through to obtain coverage. Third, they’re being given less time to complete these requirements. When the process becomes harder and timelines are shortened, fewer people enroll in benefits, and many individuals end up losing coverage altogether.
When we look at Marketplace plans, this was a major provision tied to the recent government shutdown. The bill did not include an extension of enhanced subsidies for Marketplace plans, and that issue remains under discussion. Although the government has reopened, consensus has not been reached. The Democratic Party is expected to present a proposal for review in December, with the hope of securing bipartisan support to reinstate the subsidies. However, at this point, there’s still uncertainty, as prior discussions stalled without enough votes. What is currently planned is that enhanced subsidies will expire on December 31. Beginning in January, enhanced premium tax credits will no longer be available.
If we think back to the early days of the ACA Marketplace, one of the biggest complaints was affordability. While premium tax credits and cost-sharing reductions existed, they were not sufficient to make coverage affordable for many people. When enhanced subsidies were later added, individuals who already qualified for premium tax credits received larger subsidies. In many cases, premiums dropped entirely, with some individuals paying nothing. Others saw premiums fall to reasonable levels, often $35 to $45 per month, or less than $100. Now, premiums are expected to increase by at least 75%. Many people are already seeing rates quadruple, making coverage unaffordable for a significant portion of the population.
Additionally, individuals who were previously eligible for Marketplace plans, such as DACA recipients, are no longer eligible. This compounds the issue, especially since plans were already expected to increase costs. Across the board, commercial plans, including employer‑sponsored plans, are becoming more expensive.
Carriers cite rising costs as the reason for these increases. Increased use of GLP‑1 medications such as Ozempic and Wegovy has driven costs significantly. Labor shortages and rising labor costs also factor in. These expenses are ultimately passed on to consumers. Carriers are also concerned that individuals transitioning from Medicaid to the Marketplace may be less healthy overall, further increasing costs. This anticipated risk is already being priced into higher premiums. Medicaid is one of the largest coverage programs in the U.S. Nearly half of all states have at least 20% of their residents covered by Medicaid.
Medicaid primarily covers children and older adults. Thirty‑nine percent of children are covered by Medicaid, and 63% of nursing home residents rely on Medicaid due to a lack of alternative long‑term care coverage. Adults aged 19‑64 represent about 16% of the adult population covered by Medicaid. Importantly, roughly 70% of Medicaid adults are working, 44% full time and 26% part time.Four out of every ten births in the U.S. are covered by Medicaid. Many adults on Medicaid are considered “working poor.” People with disabilities and those in nursing homes make up a large share of the program’s spending due to higher healthcare needs. The bill’s Medicaid provisions primarily affect the expansion population.
The first provision eliminates temporary incentives for states to newly adopt expansion, effective January. The second provision, effective October 2028, requires states to implement cost sharing, such as copays, for expansion adults with incomes above 100% of the Federal Poverty Level. There is currently no easy way for providers to tell which patients fall into this category, creating administrative challenges. Providers will need new workflows to manage collections for a population that historically was not part of that process, despite low collectability.
Another provision limits the federal match for emergency Medicaid for non‑citizens who don’t qualify for full Medicaid. This places the full reimbursement burden on states and is expected to reduce provider reimbursement for those services. The bill introduces work or “community engagement” requirements for Medicaid expansion applicants. Applicants must complete at least 80 hours of qualifying activity in the month before applying. Qualifying activities include work, school, volunteering, or a combination. Verification requirements vary and are often unclear, which presents challenges for both states and patients. Some groups are exempt, including parents of children under 14, caregivers for disabled individuals, pregnant individuals, those in unemployment training programs, SNAP recipients who have already met work requirements, disabled individuals, Medicare recipients, and those over age 65.
Medically frail exemptions are included but undefined. Guidance from HHS is expected. Temporary hardship exemptions exist for inpatient stays, natural disasters, federal emergencies, high‑unemployment areas, and extended travel. Medicaid renewals will now occur every six months instead of annually, beginning next year. During the COVID unwinding period, despite extensive outreach, many people lost coverage simply due to missed paperwork. Medicaid churn is common, often unnoticed until a patient seeks care. More frequent redeterminations will significantly increase coverage loss. Communication surrounding this change has been minimal, increasing the likelihood that patients will be unprepared. Retroactive coverage is also reduced. Expansion Medicaid will allow only one month of retroactive coverage; all other categories will allow two months, down from three.
States rely on provider taxes and state‑directed payments to fund Medicaid. Provider taxes can currently reach up to 6% of net patient revenue. State‑directed payments allow states to incentivize certain types of care. Under the bill, expansion states will be limited to paying providers no more than 100% of Medicare rates through state‑directed payments, and non‑expansion states up to 110%. Existing programs must eventually comply. These tools previously allowed states to maximize federal matching funds. These options will now be restricted, limiting states’ ability to fund Medicaid.
Projected federal savings include:
- $326 billion from work requirements
- $191 billion from provider tax changes
- $149 billion from state‑directed payment limits
- $122 billion from delayed QMB/CHIP enrollment streamlining
- $63 billion from increased redetermination frequency
Expansion states will experience the largest funding losses. An estimated 14.2 million people are expected to lose coverage. California, Florida, and Texas will be among the hardest hit. Uncompensated care is projected to increase by $63 billion by 2034, contributing to an estimated $25 billion in annual revenue losses for hospitals. Despite the challenges, there are steps providers can take. Education is critical. Partner with community organizations, engage in health fairs and enrollment events, and provide materials in multiple languages. Use patient portals, text messages, emails, posters, and in‑facility displays to raise awareness.
Strengthen eligibility verification, predictive analytics, and revenue cycle workflows. Ensure coverage gaps are identified early and alternative assistance options are explored. Expand medical assistance screening to include disability programs, Marketplace plans, and philanthropic funding. Advocacy is essential. Work with NAHAM, Medicaid agencies, managed care organizations, and local legislators to highlight impacts and push for change. Most importantly, leverage trusted business partners to help navigate the increased complexity of Medicaid changes.
Overall, we expect millions to lose coverage, uncompensated care to rise sharply, and revenue losses to increase significantly. Strategic coordination and proactive engagement will be essential to navigate this shift together—it is more important now than ever.
NAHAM Speaker: Thank you. That wraps up today’s session. In closing, we’d like to thank our sponsor, ElevatePFS; our presenter for sharing their time and expertise; and all of our attendees for your participation today.