Insights

Alcar Health

Natascha French — Tue, 11 Nov 2025 08:00:00 GMT

Aired: November 6, 2025

About the Webinar

Rethinking Medicaid: Turning Data Into Action Before HR1

This session breaks down what community health centers can do now to prepare for upcoming Medicaid changes in H.R. 1, which will add work requirements for some adults and require twice-yearly redeterminations beginning in 2027.

Guided by Alcar Health’s Joe Rivera (32 years in health center operations and outreach & enrollment), the webinar shows how to: identify Medicaid-eligible patients using your own data, build multi-channel outreach that actually gets a response, and choose a staffing model (in-house, virtual, or hybrid) that meets demand without overextending your team.

Why it matters: During unwinding, many patients lost coverage due to procedural issues—not eligibility. The next 15 months are critical for securing and retaining coverage to create a financial cushion before new rules take effect.

Key Takeaways

Start with data. Analyze self-pay/uninsured patients (adults & children), household size, and income to flag likely Medicaid eligibility.
Make in-reach routine. Use multi-channel communications (text, phone, email, signage, face-to-face) with clear “what/why/how” messages and easy next steps.
Activate the whole clinic. Front desk, call center, intake, providers, billing, CHWs—create simple referral workflows to enrollment staff.
Right-size your workforce. Compare in-house, virtual, and hybrid models; train teams beyond “application completion” to understand eligibility rules and follow-up.
Tighten sliding-fee workflows. Avoid “passive” sliding scale—screen for eligibility and warmly hand off to enrollment assistance.
Track outcomes. Measure applications submitted, approvals, renewals, denials/cancellations, and PMPM/encounter impact to prove ROI.

Who Should Watch

CEOs, COOs, CFOs, and Population Health leaders
Call center & front desk managers, CHW supervisors
Outreach & Enrollment directors, Rev Cycle/Billing leaders
Quality & Data/IT leaders supporting reporting and dashboards

“Obtaining and retaining coverage for the next 15 months will give health centers a cushion—a revenue buffer to offset losses after 2027. Patient data is the key. ”

— Joe Rivera

Joe Rivera
Senior Medicaid Enrollment Consultant
Alcar Health

Joe Rivera brings 32 years experience in health center operations and outreach and enrollment functions with a passion for patient access to care and health center financial sustainability. After 27 years with a Colorado community health center, Joe founded Enroll IQ Consulting and began supporting health centers and PCAs nationwide. In 2021 Joe began partnering with ALCAR Health to build both virtual and onsite enrollment teams that led to thousands of new Medic-Cal and Medicaid enrollments. He now services as Senior Medicaid Enrollment Consultant for ALCAR Health.

Johanna Cazares
Chief Growth Officer
Alcar Health

Johanna Cazares is a distinguished healthcare professional with over a decade of experience in sales, marketing, and business development, specializing in FQHCs. As the Chief Growth Officer at Alcar Health, Johanna delivers solutions rooted in empathetic care, driving growth and savings for FQHCs. A MAGIC Certified Facilitator, Johanna is committed to breaking barriers to quality healthcare, especially for underserved communities. By embodying the patient perspective, she ensures that Alcar Health's contact center augmentation and training programs optimize patient interaction and service delivery. Recognized as a thought leader and change-maker in the healthcare industry, Johanna's innovative approach and passion for service drive her mission to make a lasting impact. Her background includes key roles in national health plans, care delivery organizations, and her entrepreneurial venture which optimizes Medicare Advantage growth, and enhances patient experiences. A Southern California native, Johanna credits her diplomacy and adaptability to growing up as one of twelve children. She is a dedicated mother to three children and a much-loved fur baby named Leo. Johanna is keen to connect with professionals who share her passion for improving healthcare outcomes and experiences. Guided by the mission to empower purposeful leaders, she helps realize Alcar Health's vision of driving a positive impact in healthcare for future generations.

What You’ll Learn

How to design an in-reach campaign that reaches eligible patients quickly
Which channels drive response (and how to tailor by population)
How to structure workflows & policies so everyone can make referrals
When a virtual or hybrid enrollment team makes financial sense
How to report activity, outcomes, and ROI to leadership and boards

Resources & Next Steps

Watch Part 1: Identifying Medicaid-Eligible Patients with Your Data
Request a 30-minute consult: See sample in-reach messaging, staffing plan templates, and reporting dashboards.

Transcript

Johanna Cazares:
Welcome, everyone, and thank you for joining Part 2 of our Medicaid Webinar Series on preparing for HR1 coverage disruptions.

Our host today, Joseph Rivera, is back. Joe is Alcar Health’s Senior Medicaid Consultant, and he’ll walk us through practical steps to set up robust internal and external campaigns that ensure patients stay connected, engaged, and educated.

Joe — the floor is yours.

Joe Rivera:
Thank you, Johanna. It’s a privilege to be here and to speak with so many of you.

For those who joined our first session—welcome back. For anyone new, here’s a bit about me: I come from the health center world, spending 27 years with a community health center in southern Colorado. Most of that time, I led outreach and enrollment teams, helping thousands of patients obtain and retain Medicaid coverage.

Since 2021, I’ve had the privilege of partnering with Alcar Health on multiple projects supporting Medicaid enrollment for FQHCs across the country. This work has always been close to my heart—it’s where access, mission, and sustainability meet.

Recap of Part 1

In Part 1, we discussed how to use data to identify uninsured patients who might qualify for Medicaid.

Health centers that conduct this analysis are often surprised—finding hundreds or even thousands of existing patients who are potentially eligible. This includes many children who, with the right support, could be covered today.

Medicaid remains the financial backbone of many health centers. Knowing who your patients are, analyzing income and household data, and acting on that information are essential first steps toward financial stability.

Why Act Now

Acting now is critical.
Upcoming provisions under HR1—such as work requirements and twice-yearly redeterminations—will create unavoidable coverage losses beginning in 2027.

Patients will receive confusing notices and will need guidance to comply. Health centers that prepare now—by enrolling eligible patients and retaining current members—will build the revenue cushion needed to offset those losses later.

Implementing an In-Reach Campaign

So, what happens after you identify eligible patients?
You build a plan to reach them, engage them, and help them apply.

An effective in-reach campaign includes:

Using patient data to identify those who need assistance
Developing clear messaging: why coverage matters, what to do, and how to get help
Reaching patients through multiple channels: phone, text, email, signage, or in-person
Providing direct enrollment support
Tracking outcomes to refine your process

At Alcar Health, we’ve seen that text messaging works particularly well—patients may ignore phone calls but tend to respond to texts.

Every health center is different, but a consistent, multi-channel approach increases engagement dramatically.

Making It a Team Effort

Successful in-reach involves everyone: front desk staff, call center representatives, providers, case managers, billing, and care coordinators.

For example:

Providers can refer self-pay patients to enrollment support when making external referrals.
Billing staff can contact patients with unpaid balances and offer Medicaid assistance instead of payment plans.
CHWs and case managers can identify social barriers and connect patients with both coverage and resources.

In short—make coverage retention everyone’s responsibility.

Leadership & Buy-In

Johanna Cazares:
Joe, can you speak to how leadership buy-in plays into this process?

Joe Rivera:
Absolutely. Before starting any in-reach campaign, you need support from key leaders—your COO, CIO, and other executives—because they control access to the data, reporting tools, and staffing needed to make this work.

When everyone understands the “why” behind the campaign, participation and accountability naturally follow.

Workforce Models

Once you know who needs outreach, the next question is who will do the work?

Health centers typically choose one of three staffing models:

In-House Enrollment Teams
Virtual (Outsourced) Teams
Hybrid Models combining both

Virtual Enrollment Teams

A virtual model serves as an extension of your health center.
These teams work under your guidance, use your patient data, and follow your messaging. Communication between the health center and the virtual team is essential.

They conduct outreach via phone and text, assist patients with applications online, follow up with counties and states, and ensure approvals are completed. They also anchor patients to your health center as their primary provider to strengthen PMPM revenue.

The cost-effectiveness is significant—no office space, training, or benefits to manage—and monthly activity reports make impact clear.

In-House Teams

An in-house team provides direct, on-site support for patients.
A best practice is to have a dedicated Enrollment Manager—someone responsible for supervision, training, and reporting, not just additional duties for a director already stretched thin.

This structure ensures consistency, accountability, and measurable outcomes across departments.

Hybrid Models

The hybrid model combines the best of both:
In-house staff handle in-person enrollment and patient support, while a virtual team extends reach through phone and text.

This approach helps health centers manage larger patient lists, scale quickly, and maintain continuity even during staff shortages or turnover.

Sliding-Fee and Referral Workflows

Sliding-fee patients should never be a dead end.
Every self-pay encounter should trigger a quick Medicaid eligibility screen and a warm hand-off to an enrollment specialist.

Health centers that track and formalize this process in writing see stronger financial stability and fewer missed opportunities.

Tracking and ROI

Tracking is key to long-term success.
Monitor:

Applications submitted
Approvals vs. denials
Renewals completed
Patients anchored to your site

Consider the ROI:
If 1,000 patients become newly enrolled and your PPS rate is $200 with an average of 3 visits per year, that’s $600,000 in new revenue.

Even helping 2,500 existing Medicaid patients renew coverage could retain $1.5 million annually.

These numbers prove that outreach and enrollment are not just compliance—they’re core business strategy.

Closing Discussion

Johanna Cazares:
Joe, for leaders who already have in-house teams, how do they introduce outside help without making staff feel threatened?

Joe Rivera:
It’s about data and capacity.
When there are more patients than your team can reach, bringing in a virtual partner simply ensures no one is left behind. We’re all on the same team—helping health centers stay financially strong while keeping patients connected to care.

Johanna Cazares:
And to clarify—virtual doesn’t mean automated or AI-based. These are real people, trained professionals who become an extension of your team.

If a health center decided to launch a virtual model, how long would that take?

Joe Rivera:
Typically 30–60 days, depending on data access and communication processes. Collaboration and feedback loops determine how quickly it’s up and running.

Final Remarks

Johanna Cazares:
Thank you, Joe. Your experience and insights are invaluable—especially your reminder that this work is about people, not just policy.

For everyone who joined, stay tuned for Part 3 of our Medicaid Webinar Series, where we’ll continue exploring strategies to strengthen coverage and financial sustainability.

Joe Rivera:
Thank you, everyone. It’s been a pleasure

Alcar Health

Natascha French — Tue, 30 Sep 2025 07:00:00 GMT

Aired: September 24, 2025

About the Webinar

Rethinking Medicare: Turning Data Into Action for Underserved & Aging Populations

Hosted by Alcar Health this webinar focused on how community health centers can prepare for upcoming Medicaid changes in H.R. 1, which will add work requirements for certain adults and require patients to renew coverage twice a year starting in 2027.

Led by Alcar Health’s Senior Medicaid Enrollment Consultant Joseph Rivera, the session broke down what FQHCs can do now to get ahead:

Analyze uninsured patients, especially children and low-income adults.
Update sliding-fee and intake processes to avoid missed enrollments.
Launch strong in-reach campaigns to connect eligible patients to coverage.
Build a staffing plan that supports enrollment and retention long term.

Drawing lessons from the Medicaid unwinding—where many patients lost coverage simply because notices were confusing—the webinar stressed why the next 15 months are critical. By securing and retaining coverage now, health centers can protect access for patients and create a financial cushion before the new rules take effect.

“Obtaining and retaining coverage for the next 15 months will give health centers a cushion—a revenue buffer to offset losses after 2027. Patient data is the key. By analyzing uninsured children and adults below 138% of the federal poverty level, centers can spot red flags and act now, instead of leaving money on the table. ”

— Joe Rivera

Joe Rivera
Senior Medicaid Enrollment Consultant
Alcar Health

Johanna Cazares
Chief Growth Officer
Alcar Health

Transcript

WEBVTT

00:00:08.520 --> 00:00:16.580

Annalissa Santoemma: Hello, everyone! Thank you. We are going to get started right at the hour, so we'll give everyone a couple more minutes to join.

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Annalissa Santoemma: Okay, we're gonna go ahead and get started. Just a reminder that this is being recorded, and then if anyone would like to post any Q&A in the chat, those will be answered at the end of the webinar.

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Johanna Cazares: Thank you so much, Annalisa.

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Johanna Cazares: Well, welcome, everyone. Good morning, and thank you for joining us today.

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Johanna Cazares: I am excited to introduce our presenter, Joseph Rivera.

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Johanna Cazares: Joe brings 32 years of health center experience and out from operations and outreach and an enrollment function, with a deep passion for patient access to care and financial sustainability for the health center.

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Johanna Cazares: After spending 27 years with the Colorado Community Health Center, Joe founded EnrollIQ Consulting, where he began supporting health centers and PCAs nationwide.

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Johanna Cazares: In 2021, he partnered with Alcar Health to build a virtual and on-site enrollment team, leading to thousands of new Medi-Cal and Medicaid enrollments.

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Johanna Cazares: Today, he serves as our Senior Medicaid Enrollment Consultant for Elkhar Health, where he continues to help organizations strengthen enrollment, retention, and access strategies.

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Johanna Cazares: Welcome, Joe. Thank you so much for collaborating, and I'll go ahead and turn it over to you so that you can go ahead and share your presentation. Following the presentation, we'll regroup and we'll go through the moderated discussion.

00:05:01.760 --> 00:05:12.650

Joe Rivera: Thank you very much, Joanne. I sure appreciate that, and it is a very real pleasure to me to be, talking to you today about preparedness, really, of the

00:05:12.650 --> 00:05:23.590

Joe Rivera: for H.R. 1 and the policy changes that are coming that will profoundly impact community health centers. So if you'll give me just a moment, I'm going to share my screen and bring up the presentation, and we'll get started.

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Joe Rivera: Okay, here we go.

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Joe Rivera: Again, thank you. I've got to say that your attendance here today shows your commitment to your health center, to the mission at your health center, and to the patients that you serve.

00:05:47.370 --> 00:06:01.939

Joe Rivera: This is why I do what I do. As Joanna mentioned, I was at a community health center for 27 years and loved every minute of it, and certainly very grateful to be with you today for this presentation.

00:06:03.350 --> 00:06:20.910

Joe Rivera: We're going to dive right into this. These are some things that we can expect from this webinar today. A brief look at recent legislation and rules that are impacting health centers, the real impact to patients who have to comply with some of these rules and provisions from H.R. 1.

00:06:20.910 --> 00:06:23.589

Joe Rivera: And then, how to take a close look.

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Joe Rivera: at patient data, how taking a close look at patient data will put you ahead of the game for when H.R.1 and other policy changes are implemented.

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Joe Rivera: And then how data will help you to identify threats and opportunities. We're going to take a look at some data points, pretty simple data points, and just how beneficial they will be for you to analyze these at your health center, if you have not already done so.

00:06:48.560 --> 00:07:02.780

Joe Rivera: And then, what you can do now to mitigate the impact of HR1. We know that it's, you know, a little over a year away, but really right now is the time to start planning and strategizing for that.

00:07:03.350 --> 00:07:19.369

Joe Rivera: Before we get started, though, just to kind of take a temperature of how your… what your comfort level is with knowledge of HR1, the question is, what is your level of comfort in understanding H.R.1 and its impact on Medicaid enrollment at your health center?

00:07:19.370 --> 00:07:26.800

Joe Rivera: So, we're gonna ask Annalisa to, launch this poll, and just, please take a few seconds to

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Joe Rivera: to look at this and gauge your comfort level, then we'll come back and just briefly discuss it. Go ahead, Annalisa, please.

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Annalissa Santoemma: Can you see the poll?

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Joe Rivera: I cannot see the pole.

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Joe Rivera: I think you've got to launch the poll.

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Annalissa Santoemma: I'll relaunch it. Okay.

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Joe Rivera: There we go. Yes, there it is.

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Annalissa Santoemma: Perfect.

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Joe Rivera: And of course, H.R. 1 is the one big, beautiful bill act.

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Joe Rivera: That was signed into law just recently, and, the impact with work requirements and twice-yearly redetermination. So that's really what this is about.

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Joe Rivera: All right, thank you. Alright, so it looks like we've got some poll results here. 8% of those respondents were very comfortable, which is great. The vast majority, though, are moderately comfortable with

00:08:45.550 --> 00:09:04.650

Joe Rivera: understanding the impact on Medicaid enrollment, and that is… that is so good to hear. We have some other levels of comfort, but we're going to really dive into what those impacts are on Medicaid enrollment and… and how they affect patients and health center… health center sustainability. So, thank you for that. You can go ahead and close that.

00:09:04.700 --> 00:09:06.419

Joe Rivera: By now, Alyssa.

00:09:06.620 --> 00:09:10.410

Joe Rivera: So thank you so much for taking the time to, to respond to that poll.

00:09:17.340 --> 00:09:19.200

Joe Rivera: All right.

00:09:20.470 --> 00:09:29.619

Joe Rivera: Well, looks like it is not allowing me to advance the slides for some reason. Oh, it's because I've got to stop my share. Thank you.

00:09:29.800 --> 00:09:31.379

Joe Rivera: Alright, let's go back.

00:09:31.480 --> 00:09:33.069

Joe Rivera: I'm sorry, everyone.

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Joe Rivera: We gotta go back to the,

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Joe Rivera: Gonna have to go back to the… Presentation, here we go.

00:09:41.700 --> 00:09:43.039

Joe Rivera: Alright, let's see…

00:09:46.950 --> 00:09:54.370

Joe Rivera: All right, looks like we're having some technical difficulty here. I am unable to advance these slides, I'm not sure why.

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Johanna Cazares: Joe, go ahead and try to hit your spacebar.

00:10:01.330 --> 00:10:11.120

Joe Rivera: Yeah, that's not working, I don't know why. I'm going to… I'm going to reduce this, screen, and then put it back in presentation mode, and then let's see what happens.

00:10:19.480 --> 00:10:26.889

Joe Rivera: I really want to apologize to our audience that we're having this technical difficulty. We did test it beforehand, and it was working just great.

00:10:28.380 --> 00:10:30.450

Joe Rivera: Please, bear with me one moment.

00:10:53.120 --> 00:10:54.890

Joe Rivera: Okay, let's try this again.

00:11:07.730 --> 00:11:12.610

Joe Rivera: We may have to leave it off of presentation mode, but let's… let's try it one more time.

00:11:17.490 --> 00:11:20.329

Joe Rivera: There we go. Okay, looks like it's working.

00:11:21.470 --> 00:11:22.330

Joe Rivera: Strange.

00:11:22.990 --> 00:11:39.530

Joe Rivera: Okay, let's just take a brief look… a brief overview of H.R. 1 and Marketplace Integrity Rules. These are two policy changes that have come up, major policy changes recently. We're not going to spend a whole lot of time on the Marketplace Integrity and Affordability Rule.

00:11:39.530 --> 00:11:57.550

Joe Rivera: Because there has been some changes on that and challenges in the courts for some of those provisions. But the HR1 basically impacts Medicaid enrollment in two areas. That's work requirements, the institution of work requirements.

00:11:57.550 --> 00:12:16.350

Joe Rivera: to keep Medicaid, and also twice-yearly redeterminations. These provisions mainly impact those who are in expansion populations, so mainly expansion states. If you're not from an expansion state, I encourage you to continue to watch this.

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Joe Rivera: this webinar, because there are some points here that every state, every health center in every state should be keeping in mind, but the biggest impact from HR1 is going to be those two on

00:12:28.070 --> 00:12:37.209

Joe Rivera: Those who are ages 0 through, through 64, work requirements, ages 19 to 64. So…

00:12:37.440 --> 00:12:45.979

Joe Rivera: In those expansion populations. Work requirements are basically saying you've got to show that you are working at least 80 hours a month.

00:12:46.370 --> 00:12:55.739

Joe Rivera: And in order to continue to either apply for Medicaid or to renew your coverage when it's time to renew.

00:12:55.950 --> 00:13:01.999

Joe Rivera: So, that's… keep that in mind. It's that population, and it affects those situations.

00:13:02.000 --> 00:13:17.570

Joe Rivera: Also, there's some exemptions to the work requirements. If you are a caretaker, if you're, children or an adult, you're disabled, you are involved in volunteer or community engagement, or you have children ages 0 to 13.

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Joe Rivera: For those who have children in the home ages 14 through 18, however, even though you're caretakers, you're parents, you will need… they will need to comply with these work requirements.

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Joe Rivera: The states are going to be required to be ready by October 2026, and full implementation will be December, the end of December 2026, or the first part of January.

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Joe Rivera: So, of 2027. So, it may look like this is really down the road, but it isn't. There's so much work to do at the state level. We're going to talk about state readiness.

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Joe Rivera: For, HR1, how's each state… what is their level of readiness to implement this? And we're going to take a closer look at that.

00:14:03.490 --> 00:14:09.440

Joe Rivera: And then for Marketplace, of course, the open enrollment dates have been changed.

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Joe Rivera: From, from prior, specifically, much shorter enrollment period, open enrollment period, which is, they're, they're, they're showing to, cause some, confusion and some, some frustration in trying to, do that, in a shorter period of time.

00:14:30.840 --> 00:14:48.439

Joe Rivera: And by the way, we want to make this as informal as possible, so if you have questions, that burning question, please put it in the Q&A, and we'll try to answer it as we go along. At the end of the presentation. There'll also be a Q&A session, too, that we can answer some questions, so I just wanted to put that out there, too.

00:14:48.570 --> 00:15:02.090

Joe Rivera: Some real-world impacts on your patients. So think about this from the eyes of your patients, looking back at unwinding what they went through, and trying to redetermine, in such a short period of time.

00:15:02.090 --> 00:15:11.030

Joe Rivera: the, the frustrations that they had to go through. Work requirements, and twice-yearly, or the more frequent redeterminations.

00:15:11.030 --> 00:15:15.839

Joe Rivera: Are projected to be, very difficult, for some.

00:15:15.840 --> 00:15:30.070

Joe Rivera: So, work… the documentation compliance, understanding the notices that they'll be receiving from the, from the, Medicaid office. If they are not able to… if the state is not able to.

00:15:30.070 --> 00:15:40.509

Joe Rivera: independently verify their work status or their income, then your patients are going to receive notices that they'll have to interpret and understand in order to comply.

00:15:40.510 --> 00:15:51.880

Joe Rivera: with those requirements. We know from, from Medicaid unwinding, that has been… that was a very difficult proposition, for many patients. So those are some… some real.

00:15:51.900 --> 00:16:07.910

Joe Rivera: world impacts that, that the patients, that they can look forward to, that this is, this is going to happen. Right now, the once-yearly redetermination still is a process for many that is difficult to go through, but think about this, twice yearly, how that's going to affect them.

00:16:07.970 --> 00:16:20.239

Joe Rivera: To, to go through, to go through that process. Marketplace integrity rules, short and open enrollment, also changes to the immigration status, so, those who,

00:16:20.340 --> 00:16:31.539

Joe Rivera: understanding the… what those new rules are for immigration status. Only certain people with certain statuses will now be able to get a tax credit.

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Joe Rivera: And, and, and get that assistance to pay for their health coverage.

00:16:37.930 --> 00:16:52.110

Joe Rivera: And of course, that's going to result in some loss of coverage or disruption in coverage as a result of those changes. Same thing with the HR1 provisions and the loss of coverage as a result.

00:16:53.230 --> 00:17:02.490

Joe Rivera: We'll go to our next slide. These are what we learned from unwinding, talked a little bit about this already. This is a study or report from NAC.

00:17:02.570 --> 00:17:21.829

Joe Rivera: the National Association of Community Health Centers on the impact of unwinding for community health centers on their patients' revenue and resources. Some very interesting data from a survey that was taken. The average loss of $595,000 in revenue for health centers across the board.

00:17:21.829 --> 00:17:35.470

Joe Rivera: That was the average loss. So, your health center might… may have lost less than that, or more. There was one health center that lost up to $20 million as a result of unwinding. Just the… so many loss… such a huge loss.

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Joe Rivera: and their Medicaid members, loss of Medicaid coverage for their members really impacted their revenue and finances.

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Joe Rivera: 23% of those members were disenrolled during the redetermination process. 56% had a coverage disruption. So, what that means is that

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Joe Rivera: They may have lost their coverage temporarily because they had not complied with paperwork requirements, documentation requirements, or they turned onto another program, and that coverage did not begin right away. Perhaps they were no longer eligible for Medicaid, but now we're going to be on a marketplace plan, but that

00:18:12.670 --> 00:18:21.000

Joe Rivera: that process took some time, and they lost coverage temporarily, so it was a disruption in coverage. This last statistic was really…

00:18:21.050 --> 00:18:34.159

Joe Rivera: really telling for me. And really, thinking about your patients at your health center and how they may be affected by these changes, 86% of them identified

00:18:34.250 --> 00:18:38.649

Joe Rivera: Not understanding the renewal process as the biggest

00:18:39.120 --> 00:18:49.649

Joe Rivera: as a biggest burial to renewing… barrier to renewing their Medicaid coverage. That was the biggest barrier, is their understanding. So the notices were confusing.

00:18:49.650 --> 00:19:01.000

Joe Rivera: Some thought that they had already been on, you know, renewed and retained on Medicaid coverage when, in fact, they were getting notices asking for documentation. Others

00:19:01.250 --> 00:19:15.150

Joe Rivera: they… they lost coverage and did not realize it. It was… it was a lot of frustration. But that impacts health center finances when you, when a patient comes in and needs to see a provider, and their Medicaid coverage is no longer in effect.

00:19:15.330 --> 00:19:23.299

Joe Rivera: That's… that's big. So now somebody's got to help them. They've got to work through that process to get back onto Medicaid.

00:19:23.400 --> 00:19:31.470

Joe Rivera: But for health centers, that was the impact of unwinding. And those are just a few of the statistics from that report.

00:19:34.090 --> 00:19:45.290

Joe Rivera: I'm going to stop there, just real quick. Joanna or Annalisa, were there any questions, that, any burning questions that we can answer right now before we move on, or should we move on?

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Johanna Cazares: There was one question in the chat a bit ago, Joe. I went ahead and answered it, and the question was just around whether or not we were going to go ahead and share the slides. The answer to that is yes, as well as the recording.

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Joe Rivera: Okay, thank you, thank you for doing that.

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Johanna Cazares: You're welcome.

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Joe Rivera: Appreciate that. Got another, report here, projected enrollment losses at community health centers. This is a report from the Commonwealth Fund. The… they're projecting between 2 and 5 million losses, enrollment losses, due to HR1.

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Joe Rivera: So…

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Joe Rivera: That is enormous. This is just at health centers, it's not the overall loss. I think we've heard, you know, figures in the 10 million.

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Joe Rivera: 12 million realm of those who will lose Medicaid coverage or lose health insurance due to H.R. 1.

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Joe Rivera: But for health centers alone, it could be between 2 and 5 million. Just think what an impact that is going to make on your health centers, to your… to your revenue and your sustainability, your ability to continue to serve patients. It's, you know, Medicaid, you know, it realistically is the bread and butter

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Joe Rivera: of most community health centers. That's their largest payer mix, largest portion of their payer mix, and they're really… health centers can't afford to lose any or some of those members and still stay financially

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Joe Rivera: viable. So, that's how important it is. That's why we're having this webinar today, because of the impact that they're looking for this to happen.

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Joe Rivera: And by the way, you know, some of you might be thinking, well, you know, this is, you know, what could still change if Congress, you know, if the party shifts in Congress.

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Joe Rivera: In midterms, but truthfully, there's going to be some impact from this.

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Joe Rivera: And we're going to… we're going to feel that. Whether it is exactly the way they're projecting it now, or if it might look different, really, that impact is going to be there one way or another.

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Joe Rivera: We're going to talk about state readiness now. How are states doing right now to show their readiness for the implementation of H.R. 1? This is a really interesting

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Joe Rivera: a study done by George Washington University, their Center for Children and Families. This is one map, this is one just data point that they used. They list all states, and then states who scored poorly on readiness metrics. And so let's talk about those metrics real quick.

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Joe Rivera: Well, there's one, a few of those down. You may or may not know this, but states every month have to report to CMS on 8 specific metrics. Those metrics are call center wait times, call abandonment.

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Joe Rivera: And so this is what we're talking about, is when a member calls their Medicaid office and is requesting assistance of some kind, or they're calling there for whatever reason, and they're needing to renew their coverage, they're applying, they need help. So these metrics are really telling.

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Joe Rivera: Call center wait times, call center abandonment rate, call abandonment rate, let's see, there's, application processing time that is over 30 days.

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Joe Rivera: So, that is a red flag. We're going to talk a little bit more about that, those red flags, call, excuse me, overall renewal rate, the ex parte renewal rate, and if that's kind of a strange word for you, ex parte renewal means

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Joe Rivera: that the Medicaid office is able to, through other data sets, able to independently verify a person's income, you know, will they be able to do that for their work status later on? And in order to seamlessly either approve

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Joe Rivera: Their next, eligibility span, or deny them for cause, say, you know, showing that they're either over income and, you know, in 2027, or they… did they have gainful employment?

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Joe Rivera: And so, if they're able to determine that independently, then they'll move ahead with the processing of that renewal. If they're not, if they're unable to do that, then a notice is generally sent to the member, and they're asked to provide that information.

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Joe Rivera: But, so ex parte renewal rate is one of those metrics. Their share of enrollees disenrolled at renewal.

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Joe Rivera: So, of all those who are renewing, what is the percentage of those renewals that are actually being denied and disenrolled? So that's another metric. They're looking at procedural disenrollment rates and their share of pending reviews. How many of those

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Joe Rivera: renewals are still pending, perhaps after that 30 days, or 45 days, or 60 days, they're still pending, they have not been resolved. So, in this map here, this is, in red, those who were states who scored poorly, they had 4 or more of these metrics that they did not meet.

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Joe Rivera: And they scored poorly on these metrics. And you see the states there. There's California, Colorado, where I'm from, New Mexico, Pennsylvania.

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Joe Rivera: Those who are not lit up in red, however, still have… they just have less than four. They have… most states have at least one or two or more deficiencies in their readiness

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Joe Rivera: In these metrics, so… but these states, they're… they got 4 more. So, why are we sharing this? Well, this shows you what the challenge is right now, and what it very well could be when this is implemented in, in our…

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Joe Rivera: in your health center patients, Medicaid patients, getting the renewals done.

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Joe Rivera: Or getting an application processed, in a timely way. Are the renewals happening seamlessly?

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Joe Rivera: in your, you know, if that's going to impact whether or not they stay on the Medicaid program.

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Joe Rivera: And, of course, you know, a best practice is for health centers to be very communicative and engage with your Medicaid office. No doubt you have some of those relationships. If you don't, it's good to establish those relationships to help people, help move that processing along, but this is,

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Joe Rivera: You know, it's… it just shows, you know, the states that really have a lot of work to do still before H.R. 1 is implemented.

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Joe Rivera: We're gonna take another poll.

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Joe Rivera: This is… really, we're going to move in this part of the presentation, we're going to move into, you know, what health centers can do right now, what you are doing right now. This poll is going to address what type of strategic planning is happening at your health center to prepare for

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Joe Rivera: to prepare for HR1. So you can choose all that apply. You might be doing a number of these. One of these predictive analysis of revenue loss due to HR1 or other policy changes. I know that has been recommended by a lot of consultants who serve community health centers.

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Joe Rivera: To start looking at, you know, a percentage of loss of Medicaid

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Joe Rivera: members, and what that's going to do to your, to your revenue, and then how you can adjust or respond to that. Have you reviewed, or are you reviewing, your sliding fee policies and fee schedule? You might wonder, well, what does sliding fee have to do with this? Well, it has a lot to do with it, because

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Joe Rivera: Somebody who loses Medicaid is going to end up on sliding fee. It's going to be uncompensated care. You'll be giving them discounts for that. Is your fee schedule and your co-payment schedule for your sliding scale, is it up to date? And does it reflect the needs of your health center?

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Joe Rivera: Reviewing… have you reviewed your health center staffing model to adjust to HR1? Will you… will the staffing model look the same? Will you try to provide that same level of services that you are right now?

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Joe Rivera: Are you going to have to cut back? Some health centers are reviewing that also. Have you reviewed current operational efficiencies at front desk? You know, providers, nursing, administrative staff? What efficiencies are there that can be improved?

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Joe Rivera: To help save money, for, for when this, for when this hits. Analysis of your health center's patient payer types. Taking a prospective look. You do this every month when you have your financial

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Joe Rivera: when your health center finances come out, and you're looking at, you know, what is the trend? Are your Medicaid patient visits trending up? Are they trending down?

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Joe Rivera: your self-pay or sliding scale? Are those trending up? Are they trending down? Are you looking at that? Are you looking at what, perhaps, what the losses of what that… those trends might look like?

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Joe Rivera: Or are you still developing a strategy? Or something else? If there's something that's not listed here that, that we have listed here that you're doing, please mark others. So, Annalisa, go ahead and launch this poll, and then we'll see, we'll see what it looks like.

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Joe Rivera: And we'll give that a few more seconds.

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Joe Rivera: Annalisa, if it looks like we've gotten the majority of the responses, we can go ahead and close it.

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Joe Rivera: All right, thank you. All right, so, very nice. So, we see that, a number of you are doing, doing,

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Joe Rivera: most or some of these that we talked about. The majority, however, 60%, are still developing a strategy, and that's good. And the fact that you're thinking about this, and you're developing a strategy.

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Joe Rivera: is so important, to start planning now, strategizing now, to, to respond. We're going to look now. Thank you for that. We'll go ahead and close the poll.

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Joe Rivera: No, with everything that we've considered, you know, what are lessons from Medicaid unwinding, the, you know, what state readiness.

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Joe Rivera: what the potential revenue losses are. We're going to move into, now, just what health centers can do now. Now, the strategizing that you're doing is great. Please keep doing that to be ready. We're going to look at some very specific

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Joe Rivera: data points to… to look at or to review that will help also, that, in our view, is really vital in preparing for this. And, you know, I think I'm having problems with,

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Joe Rivera: with advancing my slides again, I think it was that crazy poll that did it to me, because I think that's when it happened last time, so please bear with me, I'm going to stop my share.

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Joe Rivera: Or actually, what I'll do is…

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Joe Rivera: Yeah, it's not even allowing me to get out of this. I'm going to stop my share. I apologize for this, for that little glitch.

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Joe Rivera: this up.

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Joe Rivera: There we go.

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Joe Rivera: There we go. Okay.

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Joe Rivera: Okay, I'm going to share my screen again.

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Joe Rivera: Alright, let's see if it works now. There we go. Oh, perfect. Okay, so why now is the time… why is now the time to act?

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Joe Rivera: Obtaining and retaining coverage for the next 15 months, is going to keep you

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Joe Rivera: Give you a cushion.

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Joe Rivera: a revenue cushion to offset the losses after 2027. There are going to be some losses, there's no way to get around it if this is implemented in the way that they are planning, but by helping your Medicaid members or your patients to obtain or retain Medicaid, now putting into place a

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Joe Rivera: a process to do that, if you're not doing it, is going to give you that cushion. It's going to help keep those finances steady prior to the implementation. Patient data will highlight where you're vulnerable and what opportunities you have to impact access to care and revenue.

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Joe Rivera: So we're going to talk at length about some data points, as I mentioned, that health centers can start looking at now in planning for.

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Joe Rivera: And then, of course, your patients are going to need reliable information about these changes. The news feeds and the media sources are out there, and there is a ton of information about HR1, about work requirements, about redeterminations, about immigration.

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Joe Rivera: And people are seeing this, and no doubt, or confused, or wondering, well, am I going to be able to keep my Medicaid or not? Is your health center… does your health center have in place some messaging on HR1? Now would be a good time to start doing that.

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Joe Rivera: By acting now on that, you'll be able to provide them information from a trusted source, and you know, again, you know, if they're already on Medicaid, this is not going to affect them until it's time for them to renew their coverage again.

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Joe Rivera: And primarily after January of 2027. But they might, you know, they may be feeling like, well, you know, do I need to do something? Am I going to lose my coverage? Please allay their fears. But now is the time to put together some messaging to benefit your patients, to allay those fears.

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Joe Rivera: Now we're going to take a look at some data points, take a closer look. You may have done this in your health center. If you have, my hat's off to you. To me, this is one of the most important data analyses you can do.

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Joe Rivera: At your health center, where… where that affects your, that affects your Medicaid revenue.

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Joe Rivera: For children, taking a closer look at children, ages 0 through 18, prospectively, over the last 12 months, everyone who has had a med… all your children who have had a Medicaid visit.

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Joe Rivera: or who were self-pay or uninsured.

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Joe Rivera: in the last 12 months that are still uninsured, and… and looking at each site, looking at this data for each site, looking at the number of children who are on Medicaid and CHIP, and the number of children who are on sliding fee… or self-pay or sliding fee only.

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Joe Rivera: Now, you might wonder, well, why would we have somebody, or have a child on sliding fee only? There are very few reasons why you would do that.

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Joe Rivera: And it really should be their only option to get medical care. Now, that could be because of their immigration status, that they're not eligible for Medicaid or any other programs, or they're over income for some of the

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Joe Rivera: Medicaid or CHIP programs in your state, but still below 200% of the federal poverty level. That's why they're on sliding fee.

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Joe Rivera: But if you see that you have children who are on sliding fee with no other payer source, that is a red flag.

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Joe Rivera: There should be no children on sliding fee only, unless that is their only option.

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Joe Rivera: Children generally also visit the doctor a few times out of the year. If they're on sliding fee, you're writing that all off, less a co-payment, and that's if you're even able to collect the copayment.

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Joe Rivera: Same thing with adults, you'll want to take a prospective look at all uninsured adults who are at or below

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Joe Rivera: 138% of the federal poverty level, that's the Magi, Medicaid, MAGI category cutoff.

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Joe Rivera: For, for the expansion population for Medicaid expansion. So if you expanded Medicaid in your.

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Joe Rivera: in your state, you haven't taken a look at this, you really should. There is not one health center that I'm aware of that has done this analysis at Alcar, and myself have, helped with this analysis, that did not show up hundreds

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Joe Rivera: of adults, if not more, who were below 138% of the federal poverty level, and sliding scale was their only option. Now, given there may be those who have no other option because of their immigration status to be on that, but

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Joe Rivera: But, we've, you know, and really sifting through that data and taking a close look at it, then, then we're able to see that there are a lot of adults, parents, single adults, couples, who are on sliding scale only, and that's it.

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Joe Rivera: And they're potentially eligible for Medicaid. So right now, if you did that analysis right now, and you look prospectively for the 12 months, you may be surprised by what you see. There's not a health center that's done this that did not find children who were on sliding scale only, and they could not explain why.

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Joe Rivera: They were not sure why that was the case, why they were not on Medicaid. So that's… that's money that health centers are leaving on the table.

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Joe Rivera: That's… that's revenue that you need

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Joe Rivera: to be generating, prior to, to January of 2027, and then putting these practices, and any improvements in place to, to help with your Medicaid members, even after January 2027.

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Joe Rivera: So this is really important. Hopefully you've done this. If you haven't, take some time to do this. Look at all of your children, uninsured children.

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Joe Rivera: who are… who have seen a provider in the last 12 months. Do you really know who they are? Do you know why they are on there?

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Joe Rivera: I have listed in here, as part of this analysis, looking at all of your Medicaid members, those who are on Medicaid now. And the reason why is because that gives you an idea of how many you have now. You're getting revenue from, that you're receiving revenue from.

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Joe Rivera: But, you could lose that revenue. So, that gives you… that gives you an idea of all of those who still need to retain their Medicaid coverage. Not everybody will.

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Joe Rivera: But if you can, if you can affect

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Joe Rivera: retention for a good portion of those, and help them with that, then you're going to retain that revenue that you need desperately, and right now.

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Joe Rivera: And so, please do this. We're encouraging to make this analysis. I know that, you know, the data that you're pulling from your EMR is,

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Joe Rivera: it, you know, it's probably overwhelming. There's a million things you can look at. Please do take the time to do this, to look at these data points.

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Joe Rivera: I'll give you an example of some findings from health centers. We've kind of talked about this already, some health centers that have done this analysis. They, identified uninsured children who are on sliding scale only, adults, the same thing. Identified patients whose payer type is unknown. I don't know if you have that in your HR, or if you've ever seen that.

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Joe Rivera: But not knowing if there's a child or an adult who's below 138% federal poverty level, if you're tracking their income and household size.

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Joe Rivera: But their… their pair type is unknown. Why is that?

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Joe Rivera: That's a red flag. Everybody should have a payer type. If it's… if it's uninsured or self-pay, okay. If it's sliding scale, great, that should be in there. Have you, health centers have, found that they've had, health insurance?

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Joe Rivera: The patients have had health insurance, but sliding scale was the primary payer.

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Joe Rivera: So, the health insurance, Medicaid, private coverage, marketplace coverage, is not being billed. Why is that?

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Joe Rivera: And sliding scale was being categorized as the primary. And if that's not changed, there might be a good reason why, but if it's not changed back, then all those visits afterward, that's going to happen.

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Joe Rivera: They're gonna just get a sliding scale discount.

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Joe Rivera: They're also able to see the total number of Medicaid and CHIP patients that they have, again, helping them to see what their revenue sources are right now, and how to retain that revenue source. They've also identified that, you know, after looking, making this analysis and seeing the amount of work that needs to be done.

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Joe Rivera: to reach and retain or to enroll these Medicaid members

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Joe Rivera: That their staffing is inadequate for that, and it allows them to take a look at their staffing model and make those changes, too.

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Joe Rivera: So FQHCs can ask these questions after doing a data analysis. Why are there children who are self-paid or sliding scale, but not on Medicaid or CHIP?

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Joe Rivera: do… have these children or parents been reached out to by an enrollment specialist? Are there plans in place to reach

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Joe Rivera: that reach out to current Medicaid members to help them retain their coverage. Are there gaps in the sliding scale application intake process, or intake process, that result in missed opportunities for Medicaid enrollment?

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Joe Rivera: We'll talk a little bit more about that as a threat.

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Joe Rivera: To, to a health center sustainability, but, front desk, sliding scale, intake, those are positions that are vital to a health center, and for it to be functioning at the very highest level.

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Joe Rivera: So identifying those threats. So some threats could be, unchanged sliding fee intake or front desk processes. If you see that these are causing a problem, that after taking a look at the data and you're seeing that

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Joe Rivera: that you've got these issues, but not changing, that is a threat. Or there has not been a review of those processes or workflows in a long time, that is a threat. There could be some efficiencies there that are affecting

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Joe Rivera: whether or not your payer mix, how many people are on Medicaid, are they being connected with an enrollment specialist to apply for Medicaid?

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Joe Rivera: The lack of uniformity in data entry and workflows, and that's across the board, with turnover and training, that could be an issue where

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Joe Rivera: things are being, you know, opportunities are being missed to help people retain or obtain Medicaid. Just keeping the status quo prior to HR1 impact or a passive response, basically doing nothing, or having a wait-and-see attitude, that is a threat.

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Joe Rivera: Let's just see how this is all going to play out. Maybe we don't have to change much.

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Joe Rivera: We don't have to spend any additional money as a result.

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Joe Rivera: That is a threat to your health center. Missed opportunities to generate revenue in the next 15 months. Some of the things we've talked about so far, about doing that data analysis and then acting on it, that's only going to help increase your Medicaid revenue, keep your self-pay or uninsured population as low as possible.

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Joe Rivera: And, and keep that revenue stream coming in.

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Joe Rivera: And then, also a higher uncompensated care and fewer resources for your patients. If a patient is lacking health insurance, whether it's Medicaid or Marketplace or any other kind of insurance than insurance coverage.

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Joe Rivera: that really closes a lot of doors for them. If they need services outside your health center, they need a referral to a specialist.

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Joe Rivera: They need to get services at a hospital. Without those resources, that really limits their access to care. And of course, it's going to affect your bottom line, too. The more uncompensated care means less revenue.

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Joe Rivera: So these are some threats, some really… some things to really think about, and we encourage you to do that. We've helped health centers to do this, to make this assessment, and really take a… take a close look at what those threats and opportunities are, but we encourage health centers to do this as soon as possible.

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Joe Rivera: Taking advantage of opportunities, so acting on your data findings as soon as possible, doing the data analysis, and then acting on it. Plan and implement a robust in-reach campaign.

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Joe Rivera: So, in-reach means your current patients, those who are utilizing your services right now, who are uninsured, reaching out to them, verifying if they have any other kind of coverage.

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Joe Rivera: At that point, and if they don't, screen them for Medicaid eligibility. That's something every health center should be doing.

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Joe Rivera: in one way or another. Depending on your model, your staffing model, it may be an outstation social service worker at your health center. You could be using an outside organization to do those enrollments for you, but

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Joe Rivera: But, you know, do something. Implement, implement that, a robust in-reach

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Joe Rivera: campaign as soon as possible. Create a staffing model that fits. Enroll all eligible children and adults in the next 15 months. In my view, in my experience, health centers should be scratching and clawing

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Joe Rivera: for every Medicaid-eligible member right now.

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Joe Rivera: And to not only improve access to care for those patients, but to also help you with your financial sustainability. We understand that you have…

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Joe Rivera: you know, unlimited priorities, so many priorities on your plate that you have to address. We're just asking, you know, make this one of them.

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Joe Rivera: And, in doing this analysis, and doing your very best to act on it, and have a strategy in place by January of 2027.

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Joe Rivera: have, you know, a staffing model, your chest pieces in place. When people start receiving those notices for work requirements or those

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Joe Rivera: frequent notices for redetermination, you have a strategy in place to help them. They're going to be reaching out to you as a trusted partner, as their healthcare provider, and wanting answers, wanting help. Please try to be ready to do that.

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Joe Rivera: Well, that brings an end to this presentation. We're going to move into Q&A right now, and hopefully this has been enlightening to you, giving you something to think about in preparing for HR1, and what you can do even right now. So, Joanna, any questions that we can pose, or I know you had

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Joe Rivera: Questions to moderate to.

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Johanna Cazares: Yeah, absolutely. Let's go ahead and check the chat.

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Johanna Cazares: Nothing there yet. We are open for questions, so please utilize the Q&A, or chat.

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Johanna Cazares: And,

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Johanna Cazares: While we wait, I'll go ahead and just dig in. So, first off, Joe, thank you so much for going through all of that information. I know there's tons, and it's all very layered. So, if we can go back to, I think, just the initial, slide, or one of the very first slides that displayed the,

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Johanna Cazares: the… 50 states, and the bulk of the states were in red.

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Johanna Cazares: That…

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Johanna Cazares: speaks volumes. I think, you know, the majority of, expansion states are included… are in red, so that…

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Johanna Cazares: Definitely surprising.

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Johanna Cazares: If you had to narrow it down, could you please, identify 3 action steps that states can take today to start, preparing for these changes?

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Joe Rivera: Yes, you know, I just… again, looking at this from the… through the eyes of a Medicaid member, that first… the first… many times, the first step in a redetermination or an application comes from a phone call.

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Joe Rivera: the member makes a phone call to the, to the Medicaid office, and how long are they waiting?

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Joe Rivera: Are there calls… are they not… are they abandoning those calls because the hold time is so high? In my experience, that's usually what happens… what happens when they call the health center. They say, look, I tried to call the county, or I tried to call the Medicaid office, and there was no answer. I couldn't wait on hold for 50 minutes, or 30 minutes.

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Joe Rivera: And so, can you help me with this? So those call wait times and abandonment times, I think, are going to be huge. To the extent that states are able to reduce that and provide that assistance as quickly as possible, I think it's going to be a game changer for many states.

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Joe Rivera: And then, the other one… I think the other one is just the processing time, past 30 days. States are, are,

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Joe Rivera: are overwhelmed, they're short-staffed, there's going to have to be some hiring of additional staff. I know that under HR1, there is millions of dollars, being allocated for, work requirements, implementing work requirements, and, twice-yearly redeterminations. Hopefully, they use that money

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Joe Rivera: to increase staff and training at the Medicaid offices. But those are, just three of, I think, that rise to the top for me on, for, for state readiness.

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Johanna Cazares: All right, and so from… thank you, from the provider perspective, what are the top three actions that health centers can take today?

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Joe Rivera: Yeah, three… so, really, some takeaways, from today's, from today's

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Joe Rivera: Webinar, is do the analysis.

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Joe Rivera: Analyze, take the time to analyze your uninsured population.

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Joe Rivera: And see, you know, and look at those specifically. Those age groups who are uninsured, 0 to 18 on the children, and then… and then adults 19 to 64 who are below 138% of the federal poverty level, looking at those who have previously had visits at your health center.

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Joe Rivera: I think what's going to happen is that you'll… by doing that, you're going to see there is… there is some room for improvement on just how data is entered in your… into your EHR, to get accurate… to get… to receive accurate data, as well as showing, you know, look, we've got some work to do.

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Joe Rivera: We've got a lot of patients… a lot of our own patients, that we need to reach out to. And so, this… so doing the data analysis. Second thing is just putting into place a strategy to do that. The in-reach… in-reach program.

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Joe Rivera: in-reach campaign, I should say. I mean, we've been talking a lot about, you know, what health centers can do, so they have all these findings from the data, and they see, okay, we've got a lot of work to do, but who's going to do that?

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Joe Rivera: who's going to do that work? We don't have the staff right now. We don't think we do have the staff right now to do that work, or the staff we do have are not adequate.

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Joe Rivera: So, that's something we're going to have. I'll just plug it right now, and a future webinar is creating a sustainable workforce to do this work, Medicaid enrollment.

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Joe Rivera: for your health center, and also in implementing an in-reach strategy, or in-reach campaign to reach those who are potentially eligible. How are we going to do that?

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Joe Rivera: And we're going to cover more of that on our next webinar. By the way, if that's a burning question for you, and you'd like to talk about that offline, we'd certainly be happy to talk to you, too.

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Joe Rivera: And give you some ideas, but we are going to have a webinar in November, for… that will address the… will address that also. Today's really was just focused on looking at the data and seeing what you find.

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Johanna Cazares: Yeah, and it looked like, just based on the poll, about 60% of the attendees today, have a strategy in development. Something that's underway, not quite, solidified yet, so I think that November 6th, webinar will be helpful, just to kind of outline and,

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Johanna Cazares: Let them know what that workforce or that, strategy implementation, requires.

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Joe Rivera: Great. So…

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Johanna Cazares: Any questions in the Q&A? No? All right, well, I have a couple more questions for you, Joe.

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Johanna Cazares: When it comes to the cost of doing nothing, if we have, you mentioned a, you know, a leader that wants to kind of just wait and see, what would you say to that, to that leader about their position on wait and see? What would the cost of doing… in this, that holding pattern look like?

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Joe Rivera: Thank you for that. Yeah, number one, it's dollars and cents.

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Joe Rivera: For the health center. If you've identified

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Joe Rivera: 500 children and adults who are potentially eligible, for instance, for Medicaid. And you're having, even right now, having a wait-and-see attitude, or viewpoint on that.

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Joe Rivera: then you are leaving money on the table. Not only that, but as I mentioned, it impacts the… it impacts your patients. It gives them less resources, less ability to seek the care that they need.

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Joe Rivera: And again, those doors are shut for them. It is… I can't stress enough just how vital it is to not do that, to not take a wait-and-see attitude. And I don't think there's many health centers who are going to do that.

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Joe Rivera: To be honest, they're going to have some strategy, work on a strategy. I guess our message today is don't wait too long to do that. You know, start working on that now or as soon as possible in identifying those ones and helping them to get onto Medicaid.

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Johanna Cazares: And you brought up a good point earlier about, health centers really leveraging the trust that they have with their patients, and ensuring that the communication is,

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Johanna Cazares: Coming from a trusted source, rather than, you know, out in media land where a lot of things can get convoluted and

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Johanna Cazares: there's so much nuance to, each patient's experience and, where they're at in their process of, redetermination or immigration, and so, I, I think that

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Johanna Cazares: That call to action is really vital as well, and kind of built into the strategy of

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Johanna Cazares: the HR1 prep.

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Johanna Cazares: Any, any final thoughts on that, specific messaging around,

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Johanna Cazares: That health centers, can share with their patients today.

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Joe Rivera: No, not really. Just, again, you know, having some messaging

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Joe Rivera: put together, you know. For instance, you know, H.R.1 is not… is going to be implemented until 2027, so these changes that they're going to… that are being talked about will not be… especially for those who are on Medicaid now.

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Joe Rivera: And they won't be impacted in that way. However, in the meantime, they may need to have a redetermination, and are they getting the help they need with that between now and then?

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Joe Rivera: And I think that's gonna be important, too.

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Johanna Cazares: And how about for patients that are in a marketplace plan right now? Any… any thoughts on that, or anything that we can share with the audience?

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Joe Rivera: Yeah, we didn't touch on this very much, but I think as our audiences may be… our audience may be well aware of, the enhanced subsidies that have been in place for the last few years, they're due to expire.

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Joe Rivera: And so, there's no doubt a lot of worry among those who are on a marketplace plan on what those premiums are going to look like next year. Are they going to be able to have the same level of health coverage that they do now? And so, that was not part of HR1, the reauthorization.

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Joe Rivera: for those enhanced subsidies that bring down those premiums. It was not in H.R. 1. Congress is still debating this. There, in fact, could be a reauthorization, but more than likely not until, later on this year, before the end of the year.

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Joe Rivera: You know, if that happens, great. If it doesn't, then there's going to be a lot of decisions that patients have to make.

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Joe Rivera: About their health coverage, and what they're willing to pay for, or the type of coverage that they're willing to pay for.

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Johanna Cazares: Alright, so more to come on that, it sounds like.

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Joe Rivera: Yeah.

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Johanna Cazares: Alright, we have about, 6 minutes left.

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Johanna Cazares: Chat is open, Q&A is open,

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Johanna Cazares: But let me go ahead and just, give you an opportunity, Joe. Can you share, without naming any names, or,

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Johanna Cazares: Anything to identify, but can you share a success story you've had with, this type of, you know, the strong in-reach process, the, you know, prioritization and, prospective data analysis, anything you can share?

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Johanna Cazares: As far as,

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Joe Rivera: Sure, I'd be happy to do that. Yeah, there was a health center I had the privilege of working with in California. They had over 100,000 patients. Their uninsured rate before putting some of these practices in place was 25%.

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Joe Rivera: That uninsured rate now is down to 4.3%.

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Joe Rivera: huge, huge difference, obviously, and… and impact on their revenue, impact on their patients. I mean, we're talking about human beings here, that are being impacted by, by things that are… many of the things that are beyond their control. And to be able to have,

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Joe Rivera: a hand in helping them with getting that access to care, I think, is one of the best things we can do.

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Johanna Cazares: Agreed. Agreed, Joe. Thank you. That's the mic drop moment right there. Let me go ahead and check our chat and Q&A.

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Johanna Cazares: Doesn't look like anybody has any questions, so, I… I want to go ahead and be respectful of everyone's time. Number one, Joe, thank you so much for your time, for sharing your… your expertise, and just your…

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Johanna Cazares: Immense knowledge on, you know.

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Johanna Cazares: this… this topic. I think it's… it's a lot of information. We're choosing to break it down in two sessions, and so I think just the… the setup of what to be looking out for today is really going to go ahead and help our audience prepare for part two, which is coming up November 6th.

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Johanna Cazares: So, again, to everyone who joined, thank you so much for your time, for your trust, and your commitment to patient care.

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Johanna Cazares: We hope you left with a, sense of urgency and the opportunity that's in front of you, so please join us for our Part 2 in this series, which will be November 6th at the same time, 10 a.m. Pacific Standard Time.

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Johanna Cazares: If you have any questions beforehand, again, like Joe mentioned,

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Johanna Cazares: We will be sending the slides out. Joe's information will be there as well, so if you'd like to offline, we're more than happy to… to connect with you as well.

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Johanna Cazares: Alright, take care, everyone. Have a great day.

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Joe Rivera: Thank you. Thank you all for attending.

Alcar Health

Natascha French — Wed, 30 Jul 2025 07:00:00 GMT

Arlette Santiago
Chief Administrative Officer, Mexico Division

At Alcar Health, we believe strong partnerships start with strong people. Our work across the U.S. and Mexico is guided by leaders who bring not just experience—but purpose. One of those leaders is Arlette Santiago, our Chief Administrative Officer for the Mexico Division.

With a background in law and international HR, Arlette supports the operational and legal foundation that allows Alcar to grow with clarity and care. In this Q&A, she shares what drives her—from loyalty and service to the joy of watching a great soccer match.

What inspired you to pursue a career in law and public service?
I like helping people, and in law and public service I found a way to do that.

What drew you to join Alcar Health, and what excites you most about our mission?
Alcar Health and I share a desire to help and solve people’s problems. I agree with its mission because we are always at the service of those who need us.

As CAO, how do you see your role supporting our growth and partnerships?
I see it as an important part—every company requires good internal organization and administration.

What’s one piece of advice you’d give to women pursuing leadership roles in traditionally male-dominated industries?
Let’s take advantage of the opportunities life gives us. Let’s not stop trying to pursue our goals. Let’s be free to make our own decisions.

What’s a value you live by—both professionally and personally?
Loyalty. To myself, my family, my friends, and my work.

What has been your proudest career moment so far?
When I see that with my work, I can change someone’s life in a way that is meaningful to them.

What’s one legal or operational challenge you think most organizations overlook when expanding internationally?
The difference between laws and requirements between countries. That’s why it’s important to hire the services of a professional in the field.

What’s a fun fact about you that most people don’t know?
I really like watching soccer—and I get really passionate when I watch a game of my favorite teams.

How do you recharge or unwind after a long day?
Reaching my house and resting, being with my children, and talking with my friends are all ways I recharge after a long day.

Coffee order of choice—or are you more of a tea person?
Always coffee.

Favorite spot in Mexico everyone should visit at least once?
Tijuana, of course! The food in this city is delicious. There are many options for drinks and amazing food. Valle de Guadalupe is a must-see—good wine, beautiful scenery, and luxurious accommodations.

If you weren’t in law, what career path would you be curious to explore?
Raising funds through events for those most in need.

What’s your go-to motivation when things get tough?
My kids. My family.

In one word, how would your team describe your leadership style?
Helpful.

About Arlette

Arlette Santiago is a lawyer and the Chief Administrative Officer of Alcar Health in Mexico. She previously led HR and legal operations for an international casino company and now helps guide Alcar’s cross-border legal and operational infrastructure. She’s also a proud mother, daughter, sister, and friend—committed to building structure through service and always leading with loyalty.

Alcar Health

Natascha French — Sun, 29 Jun 2025 07:00:00 GMT

Aired: June 26, 2025

About the Webinar

Rethinking Medicare: Turning Data Into Action for Underserved & Aging Populations

Hosted by Alcar Health, this webinar brought together leaders from JAR Insurance Services and ATI Advisory to explore how FQHCs can build meaningful Medicare strategies for dual-eligible and aging populations. With growing policy shifts on the horizon and increasing Medicare Advantage enrollment, the panel discussed actionable steps for health centers to retain patients, improve outcomes, and prepare for long-term sustainability. Topics included demographic trends, policy changes coming in 2027 and 2030, the role of culturally aligned brokers, integration of PACE programs, and practical ways to move from fee-for-service to a more engaged, managed care model.

Chapters
03:49 Understanding the Demographics and Growth of Medicare Duals
13:06 Current Trends and Challenges in FQHCs
18:42 Future Policy Shifts and Their Implications
22:01 Fee-for-Service vs. Managed Care: A Critical Discussion
23:27 The Value of Educated Agents in Medicare Advantage Plans
25:23 Navigating ACOs and Medicare Managed Care
30:44 Understanding Community Needs for Medicare Strategies
34:14 First Steps in Medicare Strategy for FQHCs
41:16 Integrating PACE Programs into Medicare Strategies
42:55 Opportunities for FQHCs in Serving Aging Populations

“We’re not just seeing aging—we’re seeing complexity. Functional, cognitive, and clinical needs are rising fast. FQHCs must prepare now to meet this moment. ”

— Kersten Lausch

Kersten Burns Lausch
Practice Director, Managed Care Strategy & Operations
ATI Advisory

Kersten Burns Lausch leads ATI's Managed Care Strategy and Operations Practice. She has spent her career working with health plans, states, providers and community partners on issues related to Medicaid, Medicare, health insurance marketplaces, delivery system reforms, and health related social needs. Prior to ATI, Lausch most recently served as Vice President of Business Development with UnitedHealthcare, where she led the organization’s Medicaid reprocurement efforts in Florida and advised health plans on organic growth strategies. Lausch previously served as a Senior Policy Director, working with individual states and Medicaid health plans to provide strategic guidance on emerging policy and program trends. Prior to joining UnitedHealthcare, Lausch served as the Director of Federal & State Affairs with the National Association of Community Health Centers where she led policy strategy and advocacy efforts to enhance the ability of federally qualified health centers to deliver integrated, high-quality care in communities across the country. Lausch has also held positions with other non-profits, including the Center for Health Research and Transformation at the University of Michigan. Lausch received her Master of Public Policy degree in health care from George Mason University and Bachelor of Art degree in political science from Hope College.

Omar Padilla
President & COO
JAR Insurance Services

Omar Padilla is the Chief Operating Officer and President of JAR Insurance Services. With over 30 years in the healthcare industry, Omar’s professional experience includes key and national leadership positions with Health Net, Molina Healthcare, United Healthcare, Blue Shield of California and now with JAR Insurance Services. Omar is responsible for ensuring all company operations run efficiently and effectively. He guides the company’s yearly strategic planning process and serves as one of the liaisons to JAR’s business partners. In collaboration with the team of JAR managers, Omar implements new business opportunities and calibrates strategies for existing projects. As a results-oriented professional, Omar is nimble, embraces technology, and is passionate about improving the existing healthcare system. He strives to educate both healthcare agents and members so they can be empowered to receive the most suitable healthcare coverage available to them. Omar was born in Torrance, California. He is married with three children and now resides in Downey, California, where he enjoys spending time with his sons and wife. Omar’s additional hobbies include hiking, cycling and golf.

Johanna Cazares
Chief Growth Officer
Alcar Health

Transcript

Speaker 3 (00:00)

Thank you so much for joining. I'm Johanna Cazares Alcar's Chief Growth Officer. Today's conversation is about moving beyond awareness into action regarding Medicare duals in FQHCs. Before we jump into our webinar today, I do want to take some time to acknowledge the challenging times and stressful situations that our communities are facing today. I'd also like to thank everyone that is working in support of the communities.

with the vulnerable and underserved, most importantly, FQHCs. And in the time where Medicaid is being obscenely threatened, I also want to acknowledge that this Medicare webinar is really intentionally placed at this time so that we can help really start a conversation about Medicare strategy and what that means for FQHCs, the benefits for their patients as well.

So let's go ahead and get started.

I'd like to invite and introduce my guests. We have two fabulous guests today. First is Omar Padilla from JAR Insurance Services. Omar, if you'd like to introduce yourself.

Speaker 2 (01:01)

Yes, hi. First, I want to say good morning. Again, my name is Omar Padilla. I'm the president and COO of JAR Insurance Services. I want to thank the Alcar team for inviting me to be part of this webinar alongside Kristen, who's such an expert in the field of Medicare dual-eligibles and I would say the health industry in general. And for everyone on the line, thank you for taking the time.

as you're representing your respective FQHCs. I think this is a critical time, which presents challenges, but also opportunities. And so welcome for joining and thank you for joining. A few highlights on my background. I have been in the healthcare industry since 1992. And throughout my career, I have been closely connected to the Medicaid and the Medicare industries.

My background includes several years of employment with some of the largest health insurance companies. And over the last 11 years, I have been with JAR Insurance Services. I can tell you that over the last 11 years, we have seen a lot of changes in the industry, but I can tell you that we have seen how Medicare Advantage has picked up momentum.

And a lot of the providers that were not traditionally focused on the Medicare industry, actually are turning more to Medicare Advantage. And so I'm happy to be part of this conversation and be able to provide information that you can find useful, not just for you, but also for the members that you serve. Back to you.

Speaker 3 (02:27)

Thank you so much, Ahmad. And I'd also like to introduce Kersten Lausch from ATI Advisory, who is going to go ahead and take us deep into some data. So Kersten, please go ahead and introduce yourself.

Speaker 1 (02:38)

And thank you for the opportunity to join you all. This is a topic I'm very excited about. And so was great to see that folks have Medicare strategies in place or thinking about it. So excited to hear more from attendees on what some of their activities look like. But as Johanna mentioned, Kersten Loesch, I'm with ATI Advisory. So we're an advisory and research firm. I lead our managed care strategy and operations practice.

And I've been with the firm for only about a year. I actually started my career at a health center. I was a case manager and loved the health center mission. Eventually through my career path ended up working at the National Association of Community Health Centers, working in partnership with the primary care associations and networks around advocacy with states as well as with CMS and a lot of VBP sort of work.

And then I felt like I couldn't be a good Medicaid advocate if I didn't understand managed care and had the chance to work at UnitedHealthcare for many years under Medicaid and dual sign of business. And so I'm really excited to chat today about kind of the Medicare space. And so as Johanna mentioned, I'm gonna share a little bit of just some grounding information and then we'll be diving into the conversation. And so as I'm going through, please.

throw your questions in the chat and we can kind of dive into that together. So I'm gonna go ahead and share here. All right. So first and foremost, just a kind of a point here around just our demographics. Looking at kind of the projected growth in the United States right now by age distribution,

You can see here on kind of this wave growth trajectory age bands, the data is showing that really we're facing significant growth in that age 85 and up population. So that's a growth of 72 % from 2022 to 2035. So rapid growth there. And then also rapid growth in that next age band of 75 to 84. And so, you

over that same kind of time period in a little bit more limited growth for that 65 to 74. So you can see a real shift in age distribution. And so as we're seeing these changes here, think recognizing the functional, cognitive, clinical complexity, medical needs that come with serving an aging population are really important. And so I think as we're kind of

diving through this conversation. think this is a good reminder of, know, just as a country overall, there's kind of a distribution of the population that is gonna have greater needs as we've kind of been talking about for a number of years, but certainly most immediately this next wave of what that really looks like.

And looking at health center patient population here, we've definitely seen over the years, health centers historically we saw oftentimes are around nine, 10 % or so of their patient population were covered by Medicare. And so either Medicare only or both Medicare and Medicaid together as an individual duly eligible for those programs. And we can see here that really that progression

you know, growth has been pretty steady. And so we'll be diving in with some questions a little bit more about this health center growth and some opportunities here. But you know, you can see it's fairly steady, a little bit more growth in Medicare overall, a little bit slower on the duals space. So those who are dual eligible for Medicaid and Medicare.

And just a little bit of level setting. you know, there's this, you know, a large portion of our population is enrolled in either Medicare or Medicaid. Just a reminder of kind of what the eligibility benefits are for those programs here as a friendly reminder. But really, we're going to focus in a good chunk of our conversation, particularly on that 13 million. So those individuals who are duly eligible for both Medicare and Medicaid.

particularly given the population that health centers serve, but also some of the changing dynamics in the marketplace.

And just looking at dual eligible individuals, to become dual eligible, you can become eligible for different reasons. Either you've turned 25 or there's have or living with a disability and have kind of gone through that SSI, SSD process. And so I think looking at the dual eligible population,

We definitely see for those who hold both Medicaid and Medicare coverage, your care needs are oftentimes more complex. So needing more assistance with daily living activities. So it goes kind of like basic activities, cooking, cleaning, taking care of ourselves, those types of pieces certainly face additional social economic barriers.

And then also there's some more complex care needs that are going on with this healthcare for those individuals. And just to kind of lay the landscape a little bit of within Medicare, you have traditional fee for service Medicare and then you have Medicare Advantage. So oftentimes referred to part C that brings in your physician and your hospital services.

And so an individual within Medicare Advantage, you could be part of a standard Medicare Advantage plan. You could be part of a chronic condition special needs plan. So there's these special needs plans that are really a subset. And the chronic condition special needs plans are really focused on tailoring services and benefits to individuals who are managing certain chronic conditions. And so

HIV AIDS, as well as cardiovascular conditions are quite popular. So tailoring plans to those individuals. Then there's ISNP or IESNP. So these are tailored to individuals who are living in long-term care, either in a long-term care facility or receiving that kind of institutional level of care somewhere in the community, or community-based.

space. And then you have a dual special needs plan. And that's for individuals who are dually eligible in both Medicaid and Medicare. Across these plans, DSNPs are the only one that have to have a contract with their state in which they're offering coverage in. And so I think that's one distinction that is going to come up as we talk more about it. But I think also flagging here, individuals who are dually eligible

can enroll in any of these Medicare Advantage plans.

And you'll see kind of over here in that break off of that D SNP area, it gets even more complex. And because really there's different levels of integration between Medicaid and Medicare when it comes to dual special needs plans. And depending on how states have organized their Medicaid programs really shapes kind of what it looks like here. And so you can have

coordination only, so they're just really kind of sharing data. You've got one plan in Medicaid, who is offering your Medicaid coverage and you have a plan in Medicare, very distinct, different. You have then a Heidi SNP, where it's a little bit more integrated, and an individual health plan. They hold at least a Medicaid contract.

and are at risk for either behavioral health services or long-term services and support, so LTSS. So they have some sort of Medicaid risk that they're bearing. And then a FIDESNIP, which is fully integrated. And this is where that Medicaid, DSNP plan is holding that Medicaid risk wholly on that Medicaid side of the house. And so really providing comprehensive services.

And so we've seen within Medicare Advantage a significant increase of enrollment over the years. And you can see in that darker red, those special needs plans has been also kind of growing relative to the growth within Medicare and Medicare Advantage. And particular growth has been in DSNP, and we'll be talking a little bit more later on of why that is.

And you can see here kind of the trajectory of what that specifically looks like for the dual special needs plans of enrollment.

And I think just one item to kind of call out, know, certainly as an individual, they're getting their Medicare, you know, services through a medic, kind of a third party partner, an independent health plan. They are also in addition to receiving, you know, what you would receive under traditional Medicare services, you're also receiving a supplemental benefits. And so there's a lot of different services that can kind of come along within that Medicare Advantage plan.

which is really important for health center patients as you think about the dental coverage that comes with many of these plants, vision, hearing, as well as all other kind of targeted supports around like medically tailored meals, for example, transportation services. And so I'm gonna stop there. That's a lot of information, but we're gonna dive in more so to the dialogue and questions now.

So please feel free to drop any questions in the chat, but I'll turn it back over to Johanna

Speaker 3 (11:44)

Thank you so much, Kersten. That was quite a lot. And I would love to just wrap up the data with a quick poll and we'll pull that up. All right. So what portion of your health center's patients are covered by Medicare? Again, multiple choice. Please go ahead and select whichever number applies to you. If it's zero to 5%, five to 10%, 10 to 15%, 15 plus, or you're not sure.

Let's see here. thought so. Okay, so 15 plus percent. Typically that ranges around 19 to 20 percent. So that looks about right. And 14 percent, not sure. There's some opportunity to dig into your data and to kind of close that question there. But great poll. Thank you so much, everyone, for participating. We'll come back into the conversation now.

And Omar, you're welcome to join back in. I'll go ahead and start off by posting a question to Kersten. I know we just looked at a lot of data on your slides. If we could just break that down a little bit further in terms of, again, focused on the duals. What does the data show us about Medicare and duals and FQHCs today? And how has it evolved in recent years?

Speaker 1 (13:06)

Sure. No, thanks, Joanna. So just as mentioning, we saw, especially when I was at NAC, this is something that me and one of my good colleagues, Susan, would often watch very closely around what is our Medicare UDS data look like this year? What are some of the things that we're seeing there? And it stayed pretty consistent. It's nice to see a more gradual increase in these recent years.

And I think you would expect that number to kind of increase given population dynamics, increases as health center patients age and really being able to be that kind of hub for the community. And I think we've definitely seen that increase. And I think there's certain something to be said about maybe why are we not seeing more of an increase? And I think.

There's a lot of dynamics that shaped that, which I know we'll talk a little bit more about. But I think some of the bumps that we're seeing in recent years, not only tied to those demographic shifts, but also more independent physicians retiring as they get older. Health centers are oftentimes really partnering with some of those providers and being able to bring those health centers into their practice, those patients into their practice.

And then also an increased interest in PACE. A couple of my colleagues really dig in and support folks on their PACE journey. And we've definitely seen increased interest amongst health centers in that space. And so I'm excited to see kind of what that data looks like over the next couple of years.

Speaker 3 (14:30)

Yeah, thank you so much. And before I turn my next question over to Omar, I did want to just mention to all of the attendees, we will be sharing the slides with you so that you have an opportunity to review them and have a conversation about them as well. So please expect those as a follow up to the webinar. Omar, from your experience, what do FQHCs tend to misunderstand or underestimate?

When it comes to the dual population, they already serve.

Speaker 2 (14:57)

Yeah, so I can tell you that historically, as we have been meeting with FQs, there tends to be an inclination to favor the fee for service environment over managed care. However, I can tell you that as I look at the poll that we just had right now, out of the FQs that actually joined this call, it seems like a lot of them do have a plan of action.

and somewhat understand what is their dual population base. But I can tell you historically we noticed that a lot of the FQs, favor that fee for service environment. I can tell you that probably it has to do for the fact that many of them maybe understood that they had more flexibility in serving their

population through that fee for service environment. I think it's possible that historically many of the FQs because they focus so much on the Medicaid population, the Medicare or the dual eligible population was more of an afterthought. And the other component too is that it does take time to formulate a strategy and a plan of action to see how you're going to increase that dual population member base with, you know, focus on Medicare and

and in a close connection to the managed care environment or MAPD plans. And I can also tell you that I think there's been misunderstanding from the FQs as to what is the financial impact, right, of moving away from that fee for service environment. But I can tell you that as we talk to many of the FQs and they begin to understand, you what is the potential that, you know, they can have by building this

mix and also by understanding that given the current environment and the data from Kristen showed it, as we've gone through the last several years, more and more of the Medicare individuals, beneficiaries, they are beginning to join MAPD plans. I think for the first time we crossed that 50 % threshold where more than 50 % of the population of the Medicare population is now in an MAPD plan. So that tells you

that there's a lot of appetite from members for those plans. And part of it is the benefits, right? And many other factors. And so I think that it's really crucial for the FQs to begin to think of a plan of action and be able to have an executable plan of action and work with the right partners so that they can maximize that opportunity. And like you said, especially in this environment right now where it seems like a lot of the health centers have to begin to

diversify that Medicaid line of business with Medicare and others.

Speaker 3 (17:29)

Yeah, thank you so much, Omar. You just reminded me of an interaction that I recently had with an FQHC that we spoke to about six or seven years ago. And at the time, it was a pretty lax strategy. We'll get to that. But what ended up triggering a phone call was our Medicaid patients are turning 65 and they're leaving.

what do we do? And so how can you help us? And so I think, you know, just one thing that I'll throw in here, the misunderstanding of just really not knowing how much patients when they're turning 65 are getting marketed to, are getting approached, and the patient sometimes thinks, once I turn 65 and I have Medicare, I guess I can go somewhere else. I guess I have to go somewhere else.

because there is no direct education to the patient. So I would say that that's a trend that we've seen more recently as well. So switching gears here. So in terms of trends, let's take a look at what's coming, what's on the future state for policy. So to Kersten, I'd like to ask,

What are the key policy shifts coming in 2027 and 2030? And what should FQHCs be preparing for tracking and just paying attention to when it comes to policy?

Speaker 1 (18:55)

Thanks, Renna. You're welcome. So I would say, first is a little bit of, there's a lot of challenge navigating these two systems. And there's a significant opportunity to really increase kind of the patient experience of, okay, I have two cards, which benefits go where? It can be very confusing. And there's additional challenges with access and whatnot.

And so there's been a real interest in improving the experience, particularly for dual eligible individuals. so CMS took action a couple of years ago and past kind of solidified some regulations to kind of push for more integration. so because of that, states are also taking action. But essentially what CMS laid out is that starting in 2027, if you are a parent company and you have a

hold a Medicaid contract and you're offering a DSNP in that same service area, you're only gonna be able to newly enroll individuals who are in your Medicaid plan. And so, that's where that new membership is gonna have to be aligned into both your Medicaid and your Medicare. And then additionally, then in 2030, taking it another step where if you have individuals enrolled in your DSNP,

who are not enrolled in your Medicaid, you're gonna actually have to disenroll those individuals out of your case net. And so states have been taking a lot of different strategies of how to align with these regulations. And so there's a lot of movement and activity, which we can certainly talk more about. I think for health centers and thinking through some of these pieces is definitely patient education. A health center,

patient can enroll if they're duly eligible for those programs, they can enroll really in any Medicare Advantage product. And there's an overwhelming number of Medicare plans available. I think the average for 2025 is 45 plan options per county. And so being able to know, you who can your patients connect with to really support them. There's brokers and partners like Omar, and there's your

state health insurance assistance programs that are really dig into this space. And so I think that's one key is also your plan partnerships. Market dynamics are shifting. So I think as from a policy context at the state level, there's some core pieces. And then I think also at a national level, we are likely going to see some Medicare demos that are really targeting alignment for dual altruists coming out of CMMI. So we actually have a webinar tomorrow and we'll be diving into that topic.

And so it's going to be something to watch.

Speaker 3 (21:35)

If you want to go ahead and pop that link into the chat before we log off, that'd be perfect opportunity. Kersten, you actually took me into my follow-up question, which was, what does that mean for FQHCs, the policy shifts between 2027 and 2030? In California, can say that we are seeing some of that activity already. So my next question, I'm going to go ahead and toss it to the both of you.

Why do you think many health centers, this is something Omar brought up earlier, default to the fee for service model? And is there any hidden cost of that decision to remain fee for service focused over time?

Speaker 2 (22:15)

I can take on that one. So as I was mentioning earlier, I feel strongly that some of the reasons why the FQs default to the fee for service, think is that there wasn't, I think in many cases, because I feel the FQs, they focus so much on that Medicaid population. I don't think they fully understood what were some of the key benefits of the

MAPD plans, not so much financially for the FQ and in terms of their growth and the way that they care for their members, but also what were the benefits for their members, for those beneficiaries. And so we've seen over the years, you know, how sophisticated the MAPD plans have become. you know, Kristen mentioned as well as other options like PACE, which seem to be right now taking off. But also, I think there's also been

sometimes lack of communication with the medical groups, IPAs or helplines that they contract and not understanding, you know, what may be challenges accessing specialists, hospitals, which I know has been an issue for many of the FQs. The other factor obviously is understanding how the reimbursement works. but like I was saying, the richness of the MAPD benefits are...

they are pretty incredible. What we see right now, there can be adjustments year over year, but overall I can tell you when a very well-educated agent is in front of a customer potential prospect, like Kristen was saying, you have an educated agent that has 40 benefit plans to offer to most individuals in most counties. The agent is probably gonna be able to have a

offer that in terms of benefits, it's going to be way richer than what they can get through a fee for service, right? And so right there upfront, you already have a challenge to any provider that is not endorsing that environment. Now, some of the hidden costs that can be associated by sticking with that fee for service environment, like you were saying earlier, Joanna, what happens is that

there are many PCPs now that do endorse that MAPD environment. So as you have FQACs that may not be endorsing it, they have the risk of having one of their members be locked in with somebody else, right? So that by itself is a loss. The other loss is that in many cases, by not having their members join some of this MAPD plans, they're missing out on benefits that are

pretty important for the members, not just the core medical benefits, but also those additional benefits that the MAPD plans offer like food and OTC, dental vision, what have you. So there are those additional costs. And the other component where I think it's a loss is that there are partners that can help the FQHCs grow, which can help with customer service.

managing many of the questions of the beneficiaries and creating that additional resource that if done correctly, the FQHCs can rely on so that they can focus on what's most important to them, starting with the clinical and free their staff to do what is more of the core function of the FQHC.

I think you're a mutagian.

Speaker 3 (25:25)

Thank you so much. I wanna go ahead. Thank you for your answer Omar and time that together. I'd like to go ahead and switch gears and just grab some questions from the Q &A. It looks like some of these questions are related to the presentation slides. So Kersten, you may wanna come off of mute, but I'll go ahead and start with a question that came in from Ralph Silver. And the question is, can you talk about how the...

proliferation of the ACOs affects our considerations about Medicare managed care for the dual eligible patients.

Speaker 1 (25:57)

One, Ralph, it's just very nice to see your name. I wish I was seeing your face too. I think, know, Ralph brings up a great fleet. Health centers that have participated in, for example, like Medicare insurance savings and some of these other models coming to CMMI have done a really nice job in serving Medicare beneficiaries and really achieving savings and demonstrating, you know,

Speaker 2 (26:20)

Dead.

Speaker 1 (26:21)

the value of the health center model in showing up for these patients. We definitely have seen some changes just given obviously one changes in the CMMI model structure and opportunities there of how health centers are thinking about their progression. But also I would say there's, think what we oftentimes and I even hear this sometimes from health centers with their PACE programs.

is just around patient education and what really kind of comes with these different pieces. You can see sometimes some churn hopping back and forth when someone sees, there's, you well, if I sign up with this plan, I'm gonna get this, you know, card that's gonna give me $200 in these sorts of benefits. Well, what are the other, you know, what are you gaining and what are you losing potentially with, you know, that sort of decision?

And so I think just being able to really support some of that education so that folks, you know, as there's a lot of advertisement and a lot of competition, that folks are being able to make choices that are really, you know, fit their healthcare needs and are really supportive there. And so I think it will be really interesting to see, you know, what does the administration come out with? Is there thinking about these Medicare demos? And

where are some opportunities for the health centers to particularly lean in and really be able to participate and continue to demonstrate that value. So I don't know, Ralph, if that helped kind of touched on your question, but that's kind of where some of my thinking is going.

Speaker 3 (27:49)

Thank you so much, Kersten. And I think we've got some chats there. Okay, so here's another question. A couple questions from Dr. Robert Beltran. Again, this is data focused. Which payer, be it Health Net Alignment Blue Shield, in the FQHC population has the largest number of Medicare or MAPD contracted?

with FQHCs.

Speaker 1 (28:15)

That's great. So the data isn't publicly available. There's definitely some ways that our firm can kind of look at some of those pieces. I would say, you know, as far as Medicare and enrollment and Medicare Advantage plans, I think you definitely see, you know, the largest enrollment across the country as a whole. I can't speak for, you know, California specifically, but you see a lot of like, you're United, Humana.

are certainly big players in that space as well as alibants and certainly then also the blues. But there are a lot of folks that are offering, but as far as kind of overall market share nationally, not specifically with health centers, that's where you see a lot of activity. But I think we also have some of that information on our website as well and some pieces. So I'll see what I can pull for you, Robert.

Speaker 3 (29:03)

Thank you, Kersten. And then just another follow up is the data California specific on your website.

Speaker 1 (29:10)

Yes, so you'll see in the question, I provided a link to one of Robert's questions around. We have a duals dashboard that allows you to look at kind of Medicare status, dual eligible status, enrollment by state. And we're actually gonna be rolling out as part of the webinar tomorrow, some additional.

information and layers around some of those dashboards. And so we're pretty excited to share so people can have more of that data in their hands.

Speaker 2 (29:37)

And let me add something to what Dr. Beltran was asking. Like in terms of the accessibility of FQs from some of the health plans and the ones that he had listed are all California or have presence in California. What I can tell you that in general, I think all three of the health plans that you mentioned have a nice mix of contracted FQHCs either directly or through some of their contracted IPAs.

Speaker 4 (29:37)

person

Speaker 2 (30:03)

And now which one has the most is hard to tell. And I have to be politically correct because I noticed that some representatives from those health plans are on the call. But I can tell you that the ones that you mentioned, all three of them have pretty broad access to FQs, not all, but many of them.

Speaker 3 (30:20)

Thank you, Omar. All right, I'm gonna go ahead and jump back into some live questions here for our panelists and then I'll go ahead and pick up back on the Q &A. So feel free to add some more questions there. For Kersten, if a health center leader were to say something to the effect of, we're not focused on Medicare right now, what trend or data point would you point them in the right direction of? Or would you show them first?

Speaker 1 (30:45)

Oh my goodness. You know, it's hard to say, cause I think being able to look at, know, there's these big national trends of what we're seeing and important indicators, like kind of I fleshed on some of the slides. But I think what I would really want to look at and show a health center leader is what's going on in your community. Obviously that's where any health center starts from, and being able to really understand and serve the, you know.

their neighbors, their family, and being able to look at like, what are the demographic shifts in your health center service area? What are you seeing as far as access needs? And what are you hearing from the patient experience as far as those individuals who are aging or who living with a disability? We've had the chance to do, in my previous world, have a chance to work with health centers and disability advocates.

to look at kind of the primary care access for individuals living with disabilities. And there's a lot of opportunity to improve care for the kind of these populations and really look at health equity and health centers, you know, live and breathe that and have been living and breathing that for, you know, well over 50 years. So I would say it's a little bit more of let's look what's going locally.

Speaker 3 (31:56)

Absolutely, thank you. Same question for you Omar, if you have, I'm sure you've had these conversations, we're not focused on Medicare right now, what trend or data point would you wanna go ahead and put in front of an FQHC leader?

Speaker 2 (32:10)

the, so I mean, not only, you know, are we going to a nice influx of people turning 65 over the next 10 years, right? We've been experiencing that wave over the last 10. And so obviously we know that the population of this country continues to age to a point where those over 65 and over 75 and 85 like Kersten was

pointing out in her data is larger, right? So what that means is that just by default, any practice out there is going to experience a larger percentage of people 65 and over. And so that is something that cannot be ignored. And if that is not the base of the population that is going to their health center, I think that it's important to take a look at.

added, right? If they have the right provider mix to take care of that population. So that is something that cannot be ignored. And also we know that the trends show that a lot of the population has more financial challenges, right? So they're more likely to be able to have a connection to an FQHC and they do live in those larger population centers.

So I think it's something that cannot be ignored. And especially given the current trends politically, no matter on what side of the scale you are, we know that there'll be potential challenges with the Medicaid population. And so that's another reason to begin to diversify and put a little more emphasis on that mix, which is leaning towards the senior population.

Speaker 3 (33:49)

Lovely. Thank you, Omar. I'm going to go ahead and just change gears here. Shifting from data to practicality. So what does it look like when an FQHC does embark on a Medicare strategy? Starting with you, Omar, what are the first steps that JAR Insurance Services takes when partnering with an FQHC and really embarking on that Medicare growth and retention journey?

Speaker 2 (34:14)

Yeah, so the, you know, I think for us, one of the first things that we like to do is we like to describe the way that we operate. And so I can tell you that over the years, our focus has always been the underserved Medicare population. And believe it or not, more than 15 years ago,

that was not a focus. Nowadays, we see a lot and more emphasis on that, you know, dual population, but it wasn't the case 15 years ago. That has been one of our focuses since we started, which is one of the reasons why we started this entity, because our organization, because back then we saw that there was a gap. Most of the agencies and agents in the Medicare industry were

not focusing on that dual eligible population. So what we like to explain is the way that we operate. We actually only work with independent agents, meaning that we will only work in areas where we have on the ground agents that understand the community. So part of what we try to instill in the, with the FQHCs that we work is the way that we operate. Then secondly, what we like to make sure that we know is

help the FQ understand that in order to be successful, they have to understand what is their current member mix and specifically identify not only what is their existing Medicare population, what is the number of members that they'll have turning 65 and above and beyond that, what is the makeup of the population that surrounds their location? So we can see what is the full potential.

And so once that is identified, then we can begin to understand what are the goals of the FQ? What is their appetite to grow that Medicare Advantage business and begin to set a plan of action that coincides with whatever is the goal of that organization. And we also need to understand what are the health plan contracts or IPA relationships they currently have so we can develop that plan of action.

and determine if we have a good foundation or if there's additional work that has to be around it. And then the last component is that we will come up with a agreed plan of action that can be possibly executed in phases, depending on the aggressiveness and the current resources that need to be deployed for the strategy. And so that's the way that we like to operate.

And but one thing to never forget is that we always put the member first. And one thing to always keep in mind is that, as you mentioned, there's many options in every market. And in order for a FQ to have a sound plan of action and be able to execute it, we need to have the right benefit plans in place that can be offered to that community.

Speaker 3 (36:55)

Absolutely. And Omar, you've mentioned before and you touched a little bit on it about the different type of agent, a different type of agent that is focused on the underserved population. What does that look like in practice?

Speaker 2 (37:08)

Yeah, the the you know, one thing that that we always come across is that as as we look, you know, in the way that many organizations try to have a marketing plan or or do outreach or what have you, you know, a lot, you know, the first thing that comes to mind is digital marketing, you know, AI and and what have you. And I can tell you that that, you know, that trend in marketing and technology cannot be applied.

to the Medicare Advantage business and to individuals because this is a different type of environment. We are in a relationship type of business. We're dealing with a product that is very difficult to understand, very complex. And the best way to serve that member population is through a very close connection between our independent agents, the staff at the clinic, the health plans, the IPAs, and that member.

technology cannot substitute the ability for someone, especially, you know, given the trends that we see with the low income population, with education levels and what have you. And so the only way that we have operated from the very beginning is that we have on the ground, independent agents that built a personal relationship, not just with the FQ that we work with, but also with the members. And that relationship, the way it starts is that

It will have several touch points. Obviously, there's the initial touch point, which is that initial introduction with the prospective member and the agent. Then there's that education session, conducting that health and financial needs analysis. And once it's all done, it's going through the process of selecting the benefit plan that is more suitable for that individual based not just on

on, like I said, health needs, but also financial needs and other specific factors. And so once the right plan is selected, actually the relationship is just getting started at that point. At that point is when we figure a way to make a connection between that individual and the clinic. And there will be a series of touch points throughout the year

that can help many factors such as star ratings, RAP scores, connection between the health center and the agent in terms of delivering messages that will help in enhancing that experience that the member not just has with the clinic, but also the health plan. And then once the next cycle comes around the next year, making sure that that whole process repeats itself. And so that anytime a member struggles,

with anything, not only do they have the clinic that they can talk to, but there is an agent that is going to be able to connect all the pieces together and ease any questions. It's a complicated process and our job is to make it as easy as possible for our partner clinics, but also for the members. And I can tell you that there's a reason why call centers have a much higher level of disenrollment and dissatisfaction than

than what the members experience through independent agents, especially those that are trained the right way and have the understanding as to what it is that it takes to service a member. And so that's the way that we operate. And I think that formula is probably the only formula that is working for those FQHCs that have a sound plan of action to increase their dual enrollments. in many cases, what

has to be done as customer service, has nothing to do with an enrollment. But when the member has the need to change their current access to care, whether it's fee for service or managed care, because not everything is for everybody, we'll have an agent that will be responsible in putting the placement of the member wherever they need to be and wherever they're gonna get the most out of it. so hopefully that explains the way that we feel

that relationship with the customer has to take place.

Speaker 3 (40:53)

Thank you. I also wanted to just pull in here, PACE, PACE being part of a broader Medicare strategy for a lot of FQHCs. As we've noticed in the experience where you just mentioned that there's not a right fit for everybody. What is your take on and that positioning that JAR takes when a patient has

It was better suited for pace as an example. How would that dynamic play out?

Speaker 2 (41:21)

Yeah, so when we partner up with health centers, medical groups, or even health plans, we have a fiduciary responsibility to do what is best for the members. And in many cases, now we're coming across individuals that are suitable for that PACE program. And so what we do is we do like to partner up with FQs that if they have that program, we'll do everything that we can to help screen and

and provide the referral as needed. It is part of doing the right thing. And in the long run, we know that as we plant seeds and we help customers and make the right or help them make the right decisions, they're gonna refer us to more friends, family members and what have you that realize that they have in us a partner that is always trying to do the best thing. And obviously we do that with full alignment with the health centers that we work with.

But at the end of the day, whatever is happening at the ground, we make sure that we notify our partners so that way they can adjust their processes, their priorities, and their structure, based on the feedback that we are able to provide.

Speaker 3 (42:24)

All right. Thank you so much. I just wanted to throw that in there because I know that there's a lot of PACE programs that are getting established throughout the FQHC community. All right. So let's go ahead and just zoom out for a moment. These shifts aren't just operational. They're about the mission of health centers. And so, Takir, I'd like to pull you back into conversation and ask one

One more direct question here. Where do you see the most significant opportunities FQHCs are missing regarding aging populations?

Speaker 1 (42:56)

That's it. man, I feel like there's definitely a lot of opportunity within the space. I think just as individuals are aging, what does it mean for kind of that retention and thinking about the care model to really meet the population's needs? Additionally, as individuals living with disabilities and who are aging and what do those needs look like?

I think one of the things where I see kind of a gap opportunity is really being able to look at the market dynamics within your state and really look at some of those shared best practices. think one of the things that health centers, a great strength is the camaraderie and network that health centers share. And so being able to talk about, know, there's some health centers that have really engaged in, built out a really stro

Medicare strategy as we've seen for some of our poll members here and being able to share that as either a health center network as through either your HTCN, your PCA, whatever that might be and really talk about how you all are approaching engaging with that aging population I think is a great opportunity right now just as we have a lot of shifts politically, policy.

demographically going on underway and I think being able to really think through the service and the care model and supports for this population and sharing that across your health center networks to get into those needs with each other I think is a great opportunity right now.

Speaker 3 (44:24)

Thank you, Kersten. That's a great closing. I will say that we have about three minutes left. So if anyone has any additional questions to pop into Q &A, let me take a look here. Okay, Dr. Beltran, it looks like we addressed this one, or Omar addressed this one, which was what is best practices for marketing to Medicare fee for service to enroll with FQHCs.

Omar, do you have anything else to add to this one? Do feel like this has been covered?

Speaker 2 (44:53)

Yeah, I think to some extent we covered it, but I mean, the best way to practice is through community-based outreach, local marketing, on the ground. We found that, know, channels such as digital marketing, direct mail, don't really have an impact. People do see it and sometimes they click on it, but they don't react to it.

So the best way to work that FQHC is by being very involved in the community, health fair, senior centers, any community health-based organization that is around that vicinity. That's the best approach and word to mouth. That has been our formula and it's a simple formula, but it takes time and it takes effort to do it. But I think especially with FQHC, that's the formula that works.

Speaker 3 (45:38)

Thank you so much Omar. I'd like to just do one final poll before we close for the day and go ahead and bring that one up.

All right, what has been the biggest barrier your organization faces when engaging dual eligible patients? Go ahead and answer as whichever one applies to you. And if it is other, please go ahead and drop that in the chat.

All right, let's see the results.

All right, 44 % lack of internal capacity. 11 % unclear policy or reimbursement models, limited education outreach, be the strategic priority and other. All right, we will go ahead and close on that note. Before we end, I'd like to just thank everyone for joining. Thank you everyone for partnering and supporting the underserved and vulnerable communities.

Thank you for your interest in our webinar. And we'll go ahead and sign off there. Take care, everyone. We will share the presentation. And if you have any final questions, you can always reach us via email as well. Thank you. Take care, everyone.

Speaker 2 (46:39)

Thank you.

Alcar Health

Natascha French — Thu, 22 May 2025 07:00:00 GMT

Aired: May 21, 2025

About the Webinar

Transforming Behavioral Health in Health Centers
This on-demand webinar explores how FQHCs can rethink their behavioral health models to better meet community needs. Led by Dr. Connie Tucker, a seasoned clinician and CMO-turned-Chief Development Officer at Ascend Healthcare, the session dives into strategies for evaluating capacity, using data to scale services, and engaging leadership to support growth. From real-time staffing metrics to patient stories that drive home the impact of care, this conversation offers tactical insights for health centers ready to expand mental health services.

Chapters
01:41 — Strategizing for Behavioral Health Capacity
04:23 — Justifying Future Investments in Behavioral Health
05:53 — Patient-Centric Stories in Behavioral Health
08:59 — Engaging Executive Leadership in Behavioral Health
16:36 — Scaling Behavioral Health Programs Effectively

“Start with the mission and ask your executive team: How do you see us healing the community? Then work backwards—tie it to your data, your staffing, and your strategy. ”

— Dr. Connie Tucker

About Dr. Connie Tucker
Chief Development Officer
Ascend Healthcare
With over 25 years of healthcare experience, Dr. Tucker is a licensed physician in Arizona and California. She earned her Doctor of Osteopathic Medicine from Midwestern University and completed her residency at John C. Lincoln Hospital System in Phoenix. She began her career with the National Health Service Corps as a Board-Certified Family Physician, later serving as staff physician and associate medical director at Mountain Park Health Center. There, she led quality initiatives, precepted for Mayo Medical School, and co-led a $4M EMR rollout across five clinics.

Dr. Tucker went on to serve as Chief Medical Officer for Gardner Family Health Centers in the Bay Area, overseeing operations for over 70,000 patients across seven sites. She later became Chief Medical Officer at NOAH in Arizona, leading medical, dental, and behavioral health services during the COVID-19 pandemic.

Today, at Ascend Healthcare, she continues her passion for delivering integrated care to underserved communities. Dr. Tucker is a graduate of Harvard and UCLA executive leadership programs and an active member of the American and Arizona Osteopathic Associations.

Transcript

Speaker 3 (00:00)

Good morning, everyone. Good afternoon for any of those that might be in the East Coast. Thank you, everyone, for joining. We wanted to go ahead and put this webinar together to share some insights on behavioral health. We've recently, Alcar Health has partnered with Descent Healthcare to introduce them and their solutions to the federal qualified health centers that we work with and beyond. With that being said, I do want to introduce myself. My name is Alex Carrillo.

I am the founder and CEO of Alcar Health. Some of you guys may be familiar with us, some of you guys may not. We are a boutique consulting firm that specializes in providing solutions to federal qualified health centers when it comes to engaging with their patients, retaining their patients and growing their patient panels, as well as providing additional services that augment the services for those patients.

With that being said, today is really all about behavioral health. With that, we have our lead speaker, Dr. Connie Tucker. So Dr. Tucker, I will turn it over to you. And if you wouldn't mind doing an intro by yourself, sharing with the team and everyone that's on the call a little bit more about yourself, and then we can jump into the webinar. Just a quick reminder, like Natasha said, we are holding questions till the end.

You are able to do questions on the Q &A and I will be monitoring those questions as well. So with that said, Dr. Connie Tucker, I will turn it over to you.

Speaker 2 (01:25)

Thank you so much again. Good morning, good afternoon, wherever you are currently watching this webinar. My name is Dr. Connie Tucker. I am a family medicine physician by training. I have dedicated my whole 25 year career to federally qualified health centers. I went to medical school to help people and I joined the National Health Service Corps right out of residency. In order to do that, I served as a National Health Service Corps loan repair recipient for 11 years and

Through that journey, I've also been a medical director and a chief medical officer. In my chief medical officer role, I also was the interim director of behavior health, which I really see health as all of us in together. It's all service lines to heal the community. Currently, I am the chief development officer for Ascend Healthcare. I was the chief medical officer for the first health center that Ascend worked with, and Ascend is a behavioral health solution.

We really provide three things. We help in the capacity where patients need access to care. We also have a clinically forward and executive team that are all clinicians. We want the patient to always be first. And then we also diversify revenue for our health centers and communities we're working with. So thank you for the time and happy mental health month. That's one of the other reasons we wanted to have this webinar. We are celebrating mental health awareness for May and

Thank you to all of you who are serving and helping patients with a mental health issue or a substance use disorder.

Again, really the thoughts and objectives for rethinking behavior health capacity is what we're working on and thinking about in this webinar. Really there's three objectives. I put them on the slide. We will get through them in order. But number one is framework for evaluating your current behavior health model. Number two is learning how to translate your community insights into a scalable solution. And then really the third one is gaining confidence in how your you plan for and justify your future investment. So before we really dive into any of those objectives, we wanted to ask a couple polling questions just to see where you all are at. So if you would be so kind to answer, the first question is, how would you describe your current behavior health model?

Speaker 1 (03:42)

Looks like we have a majority answered and I would say that about close to almost 50 % meeting needs but with strain and tied for the last three are the fully staff facing serious capacity issues and early stages of development.

Speaker 2 (03:56)

Thank you for the feedback. This is really helpful.

Okay, so really let's speak about these are the things that I've seen in my previous experience as a chief medical officer, interim director of behavior health. Really your framework should always start with data. If you think about how are you using your data to drive your decision making, if you're part of the federally qualified health center world or health center world, really the UDS report has a really a great section to show your behavior health.

percentages. If you're not a part of that health system, really what other reports can you utilize to show your behavior health need?

In that I'm gonna showcase, this is one of our collaborative partners and the CEO and people of that health center have said we could share their data. this is what the UDS table looks like. For those of you who've been on the HRSA website, you can find a lot of great information about your health center this way. This is the main page that really talks about your total patients and your percentages of who you're helping.

If you move to the services section, it's highlighted in the double blue bar. Really, the first thing to look at is how many percentage of mental health patients are you serving from your total denominator? This will show percentages and number of people.

If you aren't in a federally qualified health center in a health centers, report in these similar metrics will really help you think about your strategy moving forward. So let's go through an example. I'm not sure how many patients everyone is serving, but I picked an easy number. I like easy math here. Certainly if your health center is 25,000 patients and you're thinking about it's the year 2025,

then your goal was to serve 5 % of people and that's what you met, that would be 1,250 patients. So then you need to think about how many clinicians would I need to serve that many people in a behavioral health capacity? So if you think about the psychiatry clinician can see about 500 patients as a full caseload.

they can see about 300 encounters per month per FTE. So if you divide 1250 by 500, that would give you 2.5 for psychiatry. And this would be the team that would be prescribing medicine and co-occurring substance use disorder medications. If you're thinking about for your therapists doing traditional psychotherapy, their caseload is about a hundred. So again, just easy math, 1250 divided by a hundred is 12.5 FTEs and their KPI would be 120 encounters per month for FTE.

Being about that, you can look at your goal setting, right? You can think, this is my data. This is how many people I'd like to serve in 2025. So now what does it look like moving forward? So most strategic goals and most strategy sessions can be a one year session, can be three years, can be five years. But most people in my experience pick a modest increase year over year because you really want your team to be able to meet those goals. If you go above that, that's.

Wonderful. So let's think about a strategic goal setting for our 25,000 health center. And the team picked 2 % year over year. What we've seen in my experience are all of the people that we're working with. Most health centers are serving between about 3 to 5 % of their patients need have a behavioral health service already identified. But the national average is usually about 20%.

So again, let's look back at our 25,000 patient health center. If you remember, they were at 5 % for 2025. They wanted to get to 2 % more for 2026. So that bumped them from 5 % to 7%. So instead of that 1,250 patients, it now is 1,750. And then you can again do the math. So you'll notice for psychiatry, it bumped one person, so one FTE, to meet the need for 2 % more, but it was five therapists more to meet that. So this just gives you an idea of how to strategize for your own center.

I thought it would be nice to showcase Avalonthe again is a federally qualified health center we have in Arizona that we're helping in 2025. They're serving about 90,000 patients. The CEO there is a proponent of behavior health. He really believes that healing the community is all service lines on their health journey. And he tasked his team in 2021 to increase year over year by about 2%.

You can see in the UDS table I highlighted here for you starting in 2021. You know, they leveled out. They were about 4 % in 19, 5 % in 2020, 5 % in 2021. But the whole team jumped in and there's a lot of buy-in with this group of people and group of leaders and clinicians. Everybody is really on board to helping with the mental health percentage. And you can see they went from 5 % to 10%.

They doubled year one and almost the same for the following year. So they've hit their metrics and their goals. And that's a great way to celebrate and show the team that the data points you're picking is working.

So now that you've thought about your strategy and how many people and how do you get to those percentages, let's think about insights for scaling that solution. Again, we're gonna think about data in ways that you can expand that makes sense for your health center. So really the first thing we look at or you should think about is your behavioral health referral metrics. So some people call it the wait list, some people call it the backlog. And really as you think about best practices,

We all know the longer the patients wait for an appointment, the less likely you are to convert that.

So really, these are some of the metrics that we've noticed or I've noticed in my experience. If it's 90 days or more, you know, it usually is about a 25 % conversion rate to an appointment. 60 days or greater is about 50%. 30 days or less is about 75%. But if you can get to same day access, that's really when the patients are engaged and want the care. So if you can get your team or your...scalable solutions the same day we see it converts to about 95%.

What other things can we look at? So for our operational people out there on the webinar, really here are some other things that you can think about. Your third next available. So really you should be able to see the patients when they need you. That's a really good indicator of if you have enough staff. Next, like we mentioned for the caseload management, you can keep track of are they getting close to that 500 for a psychiatric provider?

Are they being close to that 100 caseload for the therapist? And then looking at your referral wait list, like how far out are you booking? And then what's really also important is your recruiting timeline. How quickly can you find new people, new clinicians? And then really how long does it take you to get them credentialed through the payers that are assigned to your health center or your community?

Again, here are just some goals that we've noticed or things that I've seen in my experience. Really, when you get to that third next available, if you're four weeks or more, you really should start thinking about recruiting. Again, your caseload management, if you're getting to about 75%, you wanna let the clinicians know like, we're thinking about it. We know you're getting ready to be full. We're bringing on new people.

And really, again, if you notice the conversion rate to appointments, you don't want your wait list or your backlog to be more than five days. But really, if you can get it to that same day would be your goal to have your scalable solution.

And then really thinking about how do you justify your future investment? I think it's important to mention, you the patient is always the most important thing. You know, clinical need and mission is really why we're all here and why we're helping people. So if you start with the people story, I think everything else sort of falls in line in my experience. It's always great to speak to your leaders, your CFOs, your people that you have to justify. Here's what I'm asking for the budget.

For this year, for the next year, this is how I see it, moving it forward, really utilize those operational KPIs to show your unmet need. I think that really tells a beautiful story. Listen, we're doing a great job serving, but I think we could do more. And here's why I think we could do more. And then I think it's also really important to think about if you're not serving those people that are assigned to you for their behavioral health need, they're going somewhere else.

Right. And that's really not what you want for them to have available. You want to be able to keep them in your health center and serve all of their needs. And so really think about it as a potential revenue loss for your unmet needs. If you're not seeing, you know, those 100 people, those 200 people, like what revenue are you missing for your budget? Number next, let's always think about diversifying revenue. Right. I think that's a really important thing.

You can think about your FTEs and your encounters like the math we showed before, and then project that out with your finance people and how much monies that would generate for you and your health center. And then for those of you who are in an FQHC world, don't forget about the 340B monies attached. The behavioral health medications are a great cost savings. So if you have an in-house pharmacy or contracted pharmacy, you can ask

Again, for data reports that would showcase like here are top 10 medications for psychiatry. Here's what we're prescribing for substance use disorder. And then they can extrapolate how much of those monies would be generated back to your health center and add to another part of your budget to justify your future investment. And then for finally, for those of you who are on a value based contract.

And if you're not, right, Alex, it's come in, really thinking about the quality metrics and the monies attached to your behavioral health patients, right? What are your goals? What are they expecting? Again, you can tie that to your key performance indicators and extrapolate monies coming in for that. And those of you who are attached to an accountable care organization or you have data for your emergency room, hospital admission, re-admission. Sometimes these are also tied to your value-based contracting and some monies. So a couple ways to think about how to justify your future investment.

Okay, so if it's all right, I'd like to digress just a little bit and tell you a patient's story because I believe that's why we're all here and it really showcases all the wonderful work that you're doing and why people need us.

These are the words that Karen's family and friends have been using to describe her for more than 15 years. If you ask Karen the word she would use to describe herself, they would be daughter, friend, mother of two. She's been searching for someone to help her for more than a decade. Karen is 35 years old and recently became a part of a community health center. She came with her parents looking for help about six months ago. Her parents brought her because Karen's unable to communicate her needs. She's able to speak, but her words are not ordered in a way that's understandable. She's been so depressed that she's unable to get out of bed for more than two hours at a time. She's not been able to hold a job for more than 15 years.

She's never been able to express the love she has for her two beautiful children their entire life.

Karen's family and friends were concerned that her behavior was due to methamphetamine use. When she was 20 years old, she told her parents she was having visual hallucinations. And like any of us would do, in that situation, they took her to the emergency room for answers. At the visit, she tested positive for methamphetamine. That was the one and only time that her urine drug screen was positive, but the stigma of those results stuck with her for years to come.

She wasn't able to communicate in an understandable way to her primary care doctor, her counselor, or the DES office who wanted to evaluate her for services. She would show up to her appointments and do the best she could to advocate for herself, but she often left in tears without any answers as to why she was worsening year over year.

Her PCP decided after one more frustrating appointment to reach out to a psychiatric provider to ask for assistance. She was seen the following day in the same EMR, in the same health center environment, and had a new patient psychiatric consultation. At that appointment, she was diagnosed with a disordered schizophrenia. For those of you who don't know what that medical condition is, it starts usually in your teen years and is associated with symptoms like disorganized speech, thinking, and behavior. Because of this, it made it difficult for Karen to carry out her daily tasks and communicate with others. Karen has been stigmatized and misdiagnosed for over a decade. She, like most of us, was worried about starting medication and if she could be able to afford it or if it was even on her health plan.

The team rallied around her and ensured the prescription written was affordable and she could pick it up at the pharmacy at her earliest convenience. her two week follow up, for the first time in over 15 years, she showed up for her telehealth appointment on her own and said, hi Heather, it's wonderful to see you. I'm feeling so much better. When Heather asked her in what ways are you feeling better? She said, I no longer feel trapped inside my own brain. At the end of the visit,

With tears in her eyes, she said, thank you. This team and this new medication saved my life. Three months later, Karen's now employed. She's only sleeping eight hours a night, and she's telling her kids every day that she loves them. We can't, as a team, give Karen back her 15 years, but we can continue to show her what love, care, and support looks like. Thank you.

Speaker 3 (18:48)

Dr. Tucker, thank you so much for sharing that. We do have one question that came in. And I want to go ahead and address it. Someone asked or someone mentioned

This seems like a fantastic way to look at both adding clinical value and financial benefit to any organization. What's the best way to get a buy-in from executive leadership?

Speaker 2 (19:10)

That's a wonderful question. So what I heard you asking is there's really an amazing dyad for the clinical and operational story. I would start there. really start with the mission and ask the executive team, like, what does that look like to you? Like, how do you see us healing the community? And think about it always from a patient perspective. In that. Then the next thing I would ask or show is really, well, here's the data that I've seen and this is what my team thinks it should look like. How do we get there together? That's how I would answer that question, Alex.

Speaker 3 (19:49)

Thank you. And I have a few that I'm going to go ahead and ask it while we wait for additional questions. Dr. Tucker, what are the most common reasons you see FKHCs hesitate to expand their BH programs even when the need is clear to them?

Speaker 2 (20:05)

And that's a wonderful question. think, you know, number one, I think it's just competing priorities. There's so much to do. And I totally understand that. I always say there's always joys and struggles to everything. And there's so much wonderful care and things that you can think about as a leadership team, a director, a manager, clinician, but there isn't always time. Well, there never really is time in the day to do it all. really.

Where is it prioritized? I think is sort of the number one barrier of why people don't move forward with their behavior health expansion strategies. I would say that's number one. I think number two is just sort of buy in for the team in totality, right? I think we showcased whatever your health center community is doing. If everyone's not bought in, you're really not gonna meet your metrics and goals. And I think number three is probably just staffing, truthfully. A lot of times it's hard to find clinicians and especially in the behavioral health world, it's a smaller group of people. so I would say number three is just like three is a workforce issue for sure Alex.

Speaker 3 (21:13)

No, I agree. I always say FQHC, anyone that works in FQHC wears at least two or three hats, right?

Speaker 2 (21:21)

Exactly, your job description says duties as otherwise assigned. Like sometimes you're running in that more than really what you think you should be doing. And we get that it's, you know, really part of what the mission is to serve the communities and day to day that can look different.

Speaker 3 (21:39)

Exactly. We are going to launch one more poll because it will help us understand where things are.

So the poll question number three is what will help you better advocate for behavioral health investment in your organization?

So we're clear funding paths and guidance at 44 % of answers, operational benchmarks or ROI metrics at 38%. So those are strong numbers there. Thank you for sharing that. We have a question from Grace.

What is the data of clinicians required to be trauma-informed, care certified, and should they be?

Speaker 2 (22:21)

Okay, great question. The way I hear this question and for the person who asked that, what I hear you saying is in your behavioral health strategy, what populations are you trying to serve, right? Is it general mental health? Are people designated seriously, mentally ill? Are there co-occurring substance use disorders? So when you're thinking about your FTEs, I would start there and then.

Certifications, what you think is needed. A lot of times in our behavioral-based interviewing, we ask those questions. Like, what are you comfortable serving? Like, what's your previous experience? And then, do you have any other special certifications? So usually what we see is they're EMDR certified is their most likely certification. But again, I think I would focus more on just experience. I'm not sure. The certification is mandatory unless they are providing something like EMDR.

Speaker 3 (23:17)

All right, thank you for answering that. We have one more.

From Sarah, how do you prioritize SUD, MOUD into the BH and primary care space in the FQHC setting? Are you tracking those in BH also receiving SUD services?

Speaker 2 (23:36)

Sure. I'll start with the first part of the question. In my experience, everybody needs to see it the same really in your basic, so if you're having provider meetings or clinic meetings or organizational wide meetings, I really think the best way to describe it is thinking about it without any stigma. We should all see it that way, right? The behavioral health group of people are also coming for medical or other things in your FQHC and really again, asking or thinking about it as a clinic wide organization wide that.

It's really part of the care journey and the health of the patient. So kind of wiping out that stigma, think is sort of your number one. And then really thinking about from a workflow perspective, how do you make it the easiest for the patient to get care in that service line and also make it easiest for the people that are referring to that service line? So those are two ways that I've seen it be very successful. And I think number three, yes. So reporting data is great.

And I feel you, the people that say it's one of your challenges, it is a challenging thing to export data sometimes from your electronic medical record. But what we've seen in our experience, if you're thinking about it from a population health perspective, you can ask the reporting team to put all of those ICD-9, ICD-10 codes together, right? Like here's a top 10 for psychiatry. How does it...cross-reference with substance use disorder, like how many of those patients are the same, how many are different. And that's what I would ask. Usually it's somebody on your EMR team or your IT team that can run a report from a population health perspective for you.

Speaker 3 (25:18)

I hope that that answers your question. Feel free to add to that, Sarah, if you like, or if anyone else has additional questions to add to that. We have another question that came in. And the question is, is 100 patient caseload pretty typical with an FQHC for BH therapists? Is it to moderate, outpatient, and one year? They're commenting, we are closer to 300 without an in-house psychiatry provider. Is this information available through UDS?

Speaker 2 (25:50)

Okay, great question. I'm gonna start from the beginning, Alex. So I just gave you an average. So caseloads can be different. I appreciate the color and the feedback and the questions. So it depends on what type of therapy or services they're providing, right? So if you have the traditional behavioral health consultants and they're running, you know, a quick model motivational interviewing, it's like 15 minutes, 20 minutes, then yes, it would be more than a hundred people.

Right? If you're thinking about psychotherapy and they're 30 minutes and they only get a certain amount of visits, 12 visits, 15 visits per year, and then they move on, again, yes, that would be a little bit more. The numbers that I shared are traditional psychotherapy and the maximum is about 120, 150, because there will be people that...want to be seen once a week, twice a week, they get to their goals and then they say they'll come back. And it really depends on what you're serving. But the numbers that I gave are an average and mostly for the majority of the patients would be general mental health, but the subset of seriously mentally ill or substance use disorder patients. Did that answer all those questions, Alex, or did I miss one piece? and she- I think they asked if it's on the UDS report. Yes. It is not. And so I think it's also one of the challenges for us for data. Really, some EMRs are better at this. You can track your caseload in the EMR. Sometimes they can't be tracked that way. But currently, the UDS report is not asking for that specific data.

Speaker 3 (27:31)

I will say based on our experience, not specifically to BH, but in other lines of business that we work with FQHCs, when you're working with your data teams, that data team really needs to understand what the use case is and the business case is. Because a lot of times when we're asking the FQHC leaders to provide a report back to us of some sort, and they'll send us exactly what their data team sent over, and that data is what we call it's dirty data, right? So they just extract it, send it, but because the data team doesn't understand what that data is being used for, they're not able to really dissect that data. So I would strongly recommend to sit down with your data teams, explain to them what the end goal is, because that's going to allow them to understand how to really dissect the data and give you the cleanest data available, because that data is in your EMRs in some way, shape or form, but they need to understand what the use case is.

Speaker 2 (28:26)

Yeah, no, I agree. I wholeheartedly agree with you, Alex. Really start with the why. The why is really important. This is why I'm asking. This is why I need and then really dive deep in with them to make sure you're getting the correct data that will help you move your strategy forward for sure.

Speaker 3 (28:45)

I have two more questions. One is, how do you approach staffing differently when scaling the BH program? Isn't it just about hiring more people? What's your approach when you're scaling that BH program for an FQHC?

Speaker 2 (29:01)

Yeah, that's a great question. So we currently are helping 16 community health centers. We had about 220,000 visits last year and we have about 125 clinicians. And so one of the things we think about and I've learned over my 25 years and all my gray hair, Alex is really the mission is important and how they see their piece in that puzzle. So the best that you can and what we do is we do behavioral health based interviewing. So really it's asking those important things like what are your joys? What fills your cup? What group of patients gives you the most joy and have you ever worked with this subset of patients? I think those things are really important because if they have the heart for the people in the mission, the workflows, the EMR, all of that stuff, you can train and teach people and

Those are the people that will stay. You'll have a higher turnover rate if you don't ask those questions. We also in the interview process give them an example, much like Karen's story, right? Karen's story was, you know, a beautiful testament of like, I need help and I haven't gotten anybody that has figured out how to help me. So giving like, this is the type of patient that we see, this is how we helped them. Is that something in your experience you've had or something that drives you? Towards the mission, those things really help align your workforce and decrease your turnover.

Speaker 3 (30:31)

That makes sense. I think we're getting to the end here. I have one last question and just a reminder for everyone, we are going to send a recording after this. So feel free to share it with whoever you like on your team or across any college you have. We hope that this was helpful. If you have any further questions, feel free to reach out to us. We're happy to answer any questions. Our hope for this is to be educational, to provide insights. And with that being said, there's one last question I have for you, Dr. Tucker.

Is for any organization starting to rethink their BH model, what's one step they can take tomorrow to start to move that needle?

Speaker 2 (31:08)

That's a great question. I would say really going back to like what are you currently doing? I always start, what's the why of what's driving you now? Like what are you seeing in your community? How are you helping, you know, your patients? And again, going back to if you can just get some quick data and, you know, move forward that way is a good way to start. But I think really thinking about your workflows with the primary care team.

That's the best way to move the needle quickly in my experience. So a lot of times the struggle, there's two things that people struggle with, right? Especially the primary care team. There's so much to do in 15 minutes, 20 minutes, 30 minutes, whatever that is that you can't ask all those questions and not have the resources behind it, right? So as best as you can to have a workflow for the primary care team, that's quick. One click, two clicks, here you are.

I'm gonna send the referral is number one to move the needle as quickly as you can. And then I always think people learn differently. So as you're speaking it to people also have a visual depiction of that. Some people like to hear it, but some people want to see it. Like what does that look like for me and my job? And how can I have that reference or that resource when the patient comes in? I can do it quickly. That would be my top two thoughts on that Alex.

Speaker 3 (32:35)

Awesome. Thank you. All right. Well, we'll give everyone about 20 minutes back of your day. We appreciate you making the time to join us today. Again, the recording will be emailed to everyone. If you have any additional questions, any comments, feel free to reach out. Actually, we have one more question that just came in. So that question is from Amit. And how can we best utilize our BHCs with other specialties such as pediatricians or maternal health?

Speaker 2 (33:01)

Mm-hmm. No. Is that from Dr. Ahmet Jain? Yeah. Yes. Hi, Ahmet. It's good to see you. I can't see you, but thank you for joining. He and I work together at a different health center. Again, beautiful question. I think from a pediatric standpoint and the BHCs is thinking about it in your workflows for your EPSDTs, right? The anticipatory guidance and the questions you're asking for ages and stages and milestones. You could have your behavioral health consultants jump in and think about that and then provide those resources first before you see them. And then when you come in as a provider, really, it's wonderful to see you. I know Connie spoke to you about these top three things you're thinking about for the baby. I've already gotten those resources. Like, let's move forward and think about how else we can think about the baby or the child and get them into like specialty services.

Speaker 3 (33:55)

Thank you, Connie. All right, I think that answers everyone's questions. Again, thank you, everyone. We appreciate your time. Dr. Tucker, thank you for taking your time out of your day to do this for us. We appreciate it. We hope everyone has a great day. We'll email the reporting. If you have questions, comments, feedback, we will love some feedback. Please reach out to us. Thank you, everyone.

Speaker 2 (34:15)

Thank you. Have a beautiful day!

Speaker 3 (34:18)

See you guys.

Alcar Health

Natascha French — Tue, 15 Apr 2025 07:00:00 GMT

Aired: April 11, 2025

About the Webinar
We were excited to partner with Justice in Aging to bring this exclusive webinar training to our community. Earlier this year, California implemented two new policies to simplify enrollment in Medicare Savings Programs and Part A for individuals who pay a monthly premium for Part A coverage. In this training, Justice in Aging covered the significant changes impacting how low-income individuals enroll in premium Part A and the Qualified Medicare Beneficiary (QMB) Program—a Medicare Savings Program that helps make Medicare more affordable for low-income Californians.

While most people do not pay monthly premiums for Part A, some individuals may owe up to $518 per month. QMB is currently the only Medi-Cal program that covers these premiums. This training discussed the policy changes, who was impacted, and how these updates help improve access for low-income older adults.

The webinar was hosted by Alcar Health’s Chief Growth Officer, Johanna Cazares, and featured expert training by Tiffany Huyenh-Cho, Director of California Medicare and Medicaid Advocacy at Justice in Aging.

About Tiffany Huyenh-Cho
Tiffany leads Justice in Aging’s efforts to improve the healthcare experience for Californians dually enrolled in Medicare and Medicaid. She works to strengthen Medicaid access and advocates for policies that support vulnerable older adults. Prior to joining Justice in Aging in 2021, she provided direct legal services to low-income individuals through legal aid in the Bay Area.

Transcript

Speaker 2 (05:36.558)

Good morning, everyone, and welcome. My name is Johanna Cazares and I'm honored to be here as your co-host and moderator for this important conversation brought to you in partnership by Alcar Health and Justice in Aging. Together, we're committed to equipping FQHC leaders like you with the equipment, knowledge, and tools to ensure that aging patients in your communities aren't left behind due to gaps in Medicare coverage. What inspired me to co-host this training

was what I see every day in the work that we do. Patients falling through the cracks simply because they do not have the right information or support at the right time. Whether it's confusion around enrollment or programs like the Part A buy-in, these gaps have often led to denied claims, delayed care, and unnecessary stress for aging patients. Today's training is about helping you and your teams turn that knowledge into action.

Now I'm thrilled to introduce our guest speaker from Justice in Aging, Tiffany Huyenh-Co Tiffany leads Justice in Aging's efforts to improve the experience of people who are duly enrolled in Medicare and Medicaid in California. She works to advance access to Medicaid and improve the policies and systems that affect how duly eligible individuals receive care. Tiffany brings a deep commitment to health equity

and regularly collaborates with federal, state, and local partners to make that vision a reality. She joined Justice of Aging in 2021, and before that, she served as a legal aid attorney in the Bay Area, providing direct legal representation to low-income individuals. We're excited to have her with us today as she shares her expertise in Medicare enrollment challenges, the Part A buy-in, and the opportunity for advocacy

for FQHC and their patients. Welcome, Tiffany.

Speaker 1 (07:39.31)

I appreciate the introduction and for having me here today to speak to all of you. So I appreciate all of you that are logging in early this Friday morning to join. Joanna said, might be muted.

You're muted.

Speaker 1 (07:59.534)

No one can hear me.

Speaker 2 (08:04.919)

No, you're good, Tiffany.

OK. Like Joanna said, my name is Tiffany Huyenh-Co, and I work at Justice and Aging. So I focus on people that are dually eligible for Medicare. You may also know them as duals or dual-eligibles. And today, I'm going to cover two pieces. are two new policies that started this year that are particularly relevant for this population.

Before I get into that, just a little background on justice and aging itself. We are a national organization. We use the power of law to fight senior poverty by securing access to affordable healthcare like Medicare or Medi-Cal, economic security, and the courts for older adults. We primarily focus our efforts on fighting for people who have been traditionally marginalized.

and excluded from justice such as women, people of color, LGBTQ plus individuals and people with limited English proficiency. We aren't a direct services organization. So I don't personally assist people that are duly eligible but we do more policy work within California and with the federal governments. And so we have a broad network of partners at legal aids,

at FQHCs, social workers, or health insurance counseling programs.

Speaker 1 (09:38.414)

We're committed to advancing equity for low income older adults in the areas of economic security, healthcare and housing and elder justice initiatives. And we do this by employing all of these tools here on this slide.

Okay, so here's our agenda today. I wanna make sure there should be time for questions at two parts. I will pause after we go through the first section and then at the very end of the training, I'll take time for questions. So feel free to use the Q &A function and I can get to those during today and anything I can't get to. So for today, again, I will be talking about part A buy-in and what that means in California, the benefits, the process, and why we are doing that in California. And then I'm also gonna talk about another policy that is specific to people that are on SSI or supplemental security income. And before we get into that, I'll do a background on

the Medicare Savings Program because that is the program that underlies both of these policies. So first, Medicare Savings Programs. These are Medicaid programs. They're administered by our Medi-Cal program and it makes Medicare more affordable. Medicare Savings Programs are the programs that pay for Medicare cost sharing.

paying for the co-pays, co-insurance, the monthly premiums that Medicare charges. All states have these. In California, we have these programs as well. But to qualify for a Medicare savings program, you do have to meet financial income limits. And I'll get into that in a bit. But Medicare savings programs matter because it helps pay for Medicare costs.

Speaker 1 (11:52.162)

Medicare is our federal health insurance program, as you all know, and it helps with that hospital care, routine checkups, et cetera. Medicare is vital for older adults because that is the primary program or healthcare program for people that are older and then people that are under 65 and who have a disability and receive social security disability benefits also access Medicare.

But although Medicare is comprehensive, comes at a cost. There are premiums, monthly premiums, deductibles, co-pays, and prescription costs. And then, as time goes by with inflation and everything else that is going on in the world, Medicare can be quite expensive. I think there was a statistic that says on average, Medicare enrollees pay around $8,000 a year for their coverage.

So because Medicare savings programs are vital and Medicare is not free, Medi-Cal does offer these Medicare savings programs to help pay for those costs. It's intended to make Medicare affordable. And there are four programs in California. The first three are those that are geared towards people that are lower income. And today we're gonna focus on the first one, the Qualified Medicare Beneficiary Program.

This is the Medicare savings program that will pay for your Part A premium, the Part B premium, and any cost sharing, deductibles, co-payments that come with using Part A or Part B costs. As you can notice on the slide, those three other programs that I have listed only pay for Medicare Part B premiums or Part A.

So QMB or Qualified Medicare Beneficiary Program is the most comprehensive program. And QMB is the only program that will pay for Part A premiums if you are low income. So these are really important in California itself and through other states. And to get onto these programs, you do file applications at the Medi-Cal office. They aren't administered.

Speaker 1 (14:14.21)

by Social Security, although they say Medicare, it is actually a Medi-Cal administered program.

Speaker 1 (14:24.302)

So for the Q &B program, this is again the most comprehensive of these Medicare savings programs. You have to be at or below 100 % of the federal poverty level in income. So that equates to about $1,305 a month as a single person. And you must be eligible for Medicare Part A or Part B, and Part B. People that...

are younger than 65 or don't qualify for Medicare yet, don't meet this program. This program is only for people that have Medicare and need help with the Medicare costs. And the Q and B program also beyond paying for Medicare cost also has enhanced protections. I'm sure you have all heard about improper billing for people that are duly eligible. So people with Medi-Cal and Medicare aren't responsible.

for their Medicare costs. QMB offers very strong protections under federal law so that they don't pay for these costs. And they'll also waive any late enrollment penalties. If someone enrolls into Medicare late, such as like a few years after they turn 65, Medicare will charge a late enrollment penalty. So you will see a higher monthly premium than the base premium. But if you're on the QMB program,

those late enrollment penalties are waived. The person is not paying for the actual premium or any late enrollment penalty. And then as of January, 2024, there are no longer any asset limits or asset test in our entire Medi-Cal program. People younger than 65 or people older than 65, it doesn't matter your age.

you do not have to prove your assets or keep your assets below a certain limit anymore.

Speaker 1 (16:25.314)

In the Q &B program, we find it particularly important because again, that is the only Medi-Cal program that will pay for the Part A premium. And Part A is Medicare's hospital insurance coverage. The vast majority of people have what we call free Part A. There is no monthly premium attached to enrolling into Medicare Part A. So while Medicare Part B always has a monthly premium,

Medicare Part A does not. And 99 % of people do not pay a premium for their Part A coverage, but some do. And the people that do are those that do not have enough work history in the US, meaning they haven't worked long enough in the US to pay the Medicare or Social Security taxes. So those people that don't have that work history

either on their own or through their spouse can buy into part A to get that Medicare hospital coverage, but they do face a premium for that. And it's up to $505 a month. So it's quite expensive. If you want part A and don't qualify for free, you will be charged up to $505 a month.

And so these folks that also must buy into premium part A, they have to affirmatively apply. Most people are automatically enrolled into Medicare part A or B when they turn 65 or after. Once you start receiving social security retirement, when you become Medicare eligible, you are automatically enrolled. Unless you say, I don't want to be enrolled.

But for those that have the premium part A, they are notified before and they have the option to enroll into premium part A or to decline it. And as you can imagine, a lot of people choose not to enroll into premium part A because it's expensive. $505 a month is really high. And then you're also gonna pay for your part B premium and any other Medicare costs. So the focus of our

Speaker 1 (18:42.753)

presentation today will be on these people, the people that have to buy into premium Part A. That is why we have Part A buy-in and for the qualified Medicare beneficiary program, these two pieces are really relevant to them because it makes enrollment into Part A easier and it can help pay for that Part A premium of $505 a month.

Speaker 1 (19:12.814)

Just for some demographics, like who are the people that pay for premium part A? Again, the vast majority of people don't pay a premium for part A. But for those that do, in California, the last data that we have is that as of 2021, about 181,000 people had that premium part A. And the vast majority are females. 69 % are female and the remainder are male.

They're also more likely to be a person of color in California and also across other states. And collectively, people that must pay a Part A premium owe collectively millions of dollars a year just for these Part A premiums. So the people that are most likely to have the premium Part A are older immigrants, people that immigrated into the US at an older age.

and thus didn't have the work history for free part A. It's about 10 years of full-time work to get free part A. So anyone that worked part-time might be more likely to have a premium for their part A coverage, as well as people that also just didn't enter the workforce. So women who were primarily family caregivers, and so they worked for free and did not get paid, did not pay.

into the Medicare or social security taxes or people with disabilities that maybe weren't able to work or could only find part-time work because of discrimination. So again, it's not the vast majority of people that have to pay the premium, but there is a significant population and the cost associated with premium part A are just really sky high.

So the impact is very substantial for these groups.

Speaker 1 (21:11.982)

So in 2025, there were two changes that changed the field for these people. First is the auto enrollment or automatic enrollment into QMB for anyone that is on SSI, Supplemental Security Income, and then Part A buy-in. And that's for people who are not eligible for that free Part A.

I'm going to cover these policies today, but we also created a fact sheet that was released late last year on these two policies that go into a lot more depth. I'll share the slides with everyone later, but you can also link and read more in that fact sheet as well. So first we'll discuss the automatic enrollment of SSI individuals into QMB.

This is a policy that came about under a federal law. It was a federal law that came about about two years ago. It's called the Medicaid Streamlining Rule. And basically it required states, all states to enroll supplemental security insurance people into QMB automatically. And SSI or Supplemental Security Insurance, I'm sure you know, but just as a refresher, that is a public benefit program.

It provides cash benefits to low income individuals and it's your lowest income individuals. To be on SSI, you have to have income below 100 % of the federal poverty level. And you'll notice that the SSI income limit is the same as the QMB income limit. They assist the people that are the lowest income in California.

People that get SSI are people that don't qualify for Social Security retirement. So it's also people that don't have the prior work history or a spouse also doesn't have the prior work history. It's geared towards low income people who are over 65 or people that are under 65 but have a disability. SSI benefits has their own income and their own asset limits.

Speaker 1 (23:25.282)

And if you get SSI in California, you automatically get Medi-Cal. There's no separate application for Medi-Cal if you are on SSI. You're automatically enrolled into Medi-Cal and you get Medi-Cal health benefits. But you are not automatically enrolled into QMB until this federal rule came about. So people on SSI, although categorically they qualify for the QMB program because the financial

Limits are exactly the same. You always had to apply. States did not regularly screen people, screen SSI individuals for QMB. So a lot of SSI individuals simply did not have it, even though it could have benefited them and even though they qualified. So the federal law, federal government made it required. And then as of January, 2025, all SSI individuals in California

will be automatically enrolled into the qualified Medicare beneficiary program if they are Medicare eligible.

This was actually a two phase process. The first phase started in October, 2024. But in October, 2024, not all SSI individuals were enrolled automatically. But now in January, everyone that is on SSI and qualifies for Medicare will be enrolled into QMB automatically. So what that means is,

California simply enrolls folks directly. Our Medi-Cal program gets the information from Social Security and they can directly enroll folks into the QMB program. There is no application at the county that is needed anymore and DHCS will do it at their state level system. So the counties also aren't doing this process anymore for SSI recipients.

Speaker 1 (25:32.27)

SSI recipients do not need to submit an application. There's no paper application for an SSI recipient for QMB. And again, this is because SSI recipients are financially eligible for QMB because the income limits are simply identical. But this means that people that don't have SSI, they are not automatically enrolled into the QMB program.

So those folks still have to apply, but any SSI individual, it will be done for them. So it just makes it a lot easier. If a person on SSI has premium Part A when they are enrolled into Q &B by the state, the state will also start paying for their Part A premiums because that is a feature of our Q &B program. There is no two-step process anymore.

I know a lot of you had helped a lot of people get into Medicare Part A and Q &B using the conditional Part A application where you had to go to the Social Security office to first conditionally apply for Part A and then go to the county to apply for Q &B. So for SSI recipients, that process is eliminated. They do not need to do anything really. The state

should be enrolling them directly and enrolling them into part A if it's needed. If you are seeing that this is not happening to your SSI patients, then let me know. So far, we've been assured that the process is going smoothly. I know that in January, there was several hundred thousand people that were successfully enrolled directly.

And that process will be ongoing. If you're on SSI and you age into Medicare, this will happen to you. If you're on Medicare and get onto SSI, this will also be the same process where they are automatically enrolled. So it's really great. It simplifies this piece, which as you know, is always very complicated. And this is the notice, a sample notice that the state Medi-Cal program sends out.

Speaker 1 (27:55.298)

to these members to let them know. So you may see these notices or hear of people getting them, but this is pretty much what it looks like. And the state actually, I don't know why I just checked this morning, but they used to have a page where they linked to these notices in a PDF file, but they took it down recently. So I'm not sure why I can try and find the PDF versions and send them out so you have a clearer view, but.

This is pretty much what it looks like. Anyone that is also enrolled into part A will get a separate notice from the social security office. And the social security office notice will say, you have been enrolled into part A. If someone is being enrolled into part A, they'll also get a new Medicare card from social security that also lists their new part A benefits.

All right, so the next piece is part A buy-in. The first piece I would say I think is more simple because it's clear. If you're of SSI, you're automatically enrolled into QMB and any Medicare that you need. But part A buy-in is a little bit more complicated, but under part A buy-in, this started in 2025 and it is focused on the way that California

Speaker 1 (29:52.93)

pays for these Part A premiums for people that need it. Part A buy-in is simply refers to the arrangement through which our Medi-Cal program pays the Part A premiums on behalf of eligible individuals.

Part B and other Medicare cost sharing is paid for under QMB and also through our other Medi-Cal categories. We actually have a very comprehensive Medi-Cal program and they'll pay for any Part B costs through like Aged and Disabled or any other Medi-Cal category. But Part A premiums again is only paid for through QMB. So you must have the QMB

program to get payment or help with your part a premiums. Otherwise you do have to pay that on your own. So under part a buy in California will directly enroll certain people into premium part a any time of the year and establish payment of those part a premiums via Q and B. This began January 1st, 2025 and it came about through.

Legislation that was passed a couple of years ago, it took a little bit to get implemented in January 2025, was the first date. And part A buy-in does not impact people that qualify for free part A. If you have free part A, you can enroll year round. When you turn 65, you are gonna be automatically put into free part A. But if you do not qualify for that free part A,

Those folks will have the option to enroll into premium part A. If you decline it, you have to wait until certain enrollment periods to enroll into Medicare. Like all other insurance, Medicare has restrictive enrollment periods. But if you are low income and qualify for our Q &B program, you can enroll year round through our part A buy-in program.

Speaker 1 (32:02.99)

And that's simply because the California or Medi-Cal program will do it directly. So prior to January 2025, we had a two step process to do this. You had to first go to Social Security and apply for conditional part A, but you could only do it between January to March. So if you enrolled outside of that three month window, you had to wait until the next year. And as you can imagine,

And as I know a lot of you experienced, people don't come back the next year to enroll. Or it's too confusing because you have to go to Social Security and then you have to go to the Medi-Cal office to apply for the Q &B application. So there are two applications at two different offices. And in our experience, both the Medi-Cal offices and Social Security workers were not necessarily very knowledgeable about this two-step process.

For most people, now that we are part A buy-in state, this two-step process has been eliminated.

And so why did we do this? The benefits of this are many. First, again, it simplifies enrollment for people who have to buy into part A. For most people, that two-step process is eliminated altogether. You can enroll year-round into premium part A. And it also eliminates the part A late enrollment penalties.

If California used to pay the late enrollment penalties to Social Security for anyone on QMB, but those are now eliminated, Social Security is waiving that for California. So it's actually saving the state money. It also, I think most importantly, helps people become fully, dually eligible with part A and part B. That means people who

Speaker 1 (34:03.894)

in the past maybe only had part B, you had a much more limited range of Medicare providers because Medi-Cal was paying for your hospital costs. So you had to go through the Medi-Cal network. But if you have part A and part B, you just have a much wider range of Medicare providers that are available to you. And that also means you have more Medicare enrollment options.

If you want to join a Medicare Advantage plan, the Part C plans, you have to have both Part A and Part B. So by becoming a full dual eligible, you now have access to those Part C Medicare Advantage plans, as well as the dual eligible special needs plans that are specifically catered to this group. So their benefits have been

Multi-fold state savings, but also on the individual, it's just much simpler. And then now you have help with your part A premiums and you don't have to jump through as many hoops. So it's been really great to see that this has happened in California. It's been a long time coming. We were one of, I think, 12 states that did not have this part A buy-in process.

So we were actually in the minority of states to just make it much more complicated than it really needed to be.

So what is the process today? There are two different processes for separate groups. Your first group is your SSI folks. For them, it's pretty much automatic. And then you have everyone else, people that don't qualify for SSI but are eligible for Medicare.

Speaker 1 (36:02.766)

So people that are on SSI, I've covered this before, but it's much easier. They're directly enrolled into both Q and B and then part A if needed. If they don't yet have part B, California also does that through our separate part B buy-in process that's been around for decades. And then this is an ongoing policy. Again, it's gonna apply to current SSI individuals and anyone that's newly eligible and that gets on.

in the coming months or years.

So here's a quick example. In December 2024, Lynn is 68. She receives SSI, SSP. She has SSI-linked Medi-Cal and Part B and Part D. She does not qualify for free Part A. And years ago, when given the chance, chose not to enroll. She could not afford the high cost.

Speaker 1 (36:59.31)

So in January, after we became a Part A buy-in state, California, our Medi-Cal agency, deems her eligible for QMB. She has SSI, she meets the income requirements for the QMB program. So they deem her eligible for both QMB and Part A, and in February, that is when the coverage starts. Your QMB effective date is always the first of the month following your application.

It's not immediate, so it's usually a month after. So that's why February 1st is when Lynn's Q &B coverage is effective and same with her Part A. She will not pay the premium for Part A, that's paid by the state. And then she will get the notices in the mail. She's been enrolled in Part A, Curriculum B, and she'll get a new Medicare card because now she has both A and B enrollment. Much simpler.

and much easier. But for people who don't have SSI, it's not gonna be as straightforward, unfortunately. For these folks, you do always have to apply for QMB to be evaluated. Not everyone is going to be income eligible for QMB because you have to have income at or below 1,305 a month. That's 100 % of the federal profit available.

And then for some people, just applying for Q and B alone is enough to be enrolled into premium part A, but not for everyone. And that is because you have to establish that you even qualify for Medicare. Our Medi-Cal program does not know if someone is eligible for Medicare or not. That is on the social security side because they will look at age and work requirements and whether someone has that work history.

There are two groups that fall into this non SSI automatic group. So there are those that are enrolled in part B now, but chose not to enroll into premium part A years ago. And then there are those that are not enrolled in either. They either just became Medicare eligible or for some reason has declined both premium part A and part B years ago.

Speaker 1 (39:23.79)

So the process for these two groups are going to be different under part A buy-in. If you're already enrolled into part B, you've established that you qualify for Medicare. So it's much simpler. They can apply for Q &B only, just like the SSI group. And if they qualify for Q &B, California will enroll them into premium part A and begin payment of their part A premiums. So for the...

group that's already enrolled in Part B and have established Medicare entitlement. It's simple, that two-step process is gone. You don't need to go to Social Security to apply for Part A. Applying for Q &B alone will be enough because you've already established Medicare entitlement through that Part B coverage. But if you're in Group 2 and you have not yet established that you qualify for Medicare, you do have to go to Social Security and apply.

and they have the choice of applying for part B alone. After they apply for part B, they'll be like the first group. They can apply for Q and B, California can evaluate them, and if they're eligible for Q and B, they're enrolled in part A.

You can also choose to apply for conditional Part A. That process is still an option, but it's not a requirement. And conditional Part A is the application telling Social Security that I am applying for Part A with a premium, but on the condition that I later qualify for Q &B so I get the state payment of my Part A premiums. These folks are applying for Part A conditionally.

because they don't want to be on the hook for those high Part A premiums if they won't get Medi-Cal help through the Q &B program. For the second group, you again have the option. I can't say what is a better option if they want to apply for Part B and conditional Part A to establish the Medicare entitlement or only apply for Part B alone.

Speaker 1 (41:38.062)

I know that you can do both. It may be easier to do the part B and conditional part A just so you have it in one bucket. I'd be curious to know if you have any experience with people that have tried this and what their experience have been. But in all cases, this group still has to, after they've applied for Medicare at Social Security, then file an application for Q &B at the Medi-Cal office.

So this group still has a two-step process, but hopefully there's few and fewer people on group two and most people have part B, so that if you're a group one, you only have to do one application. We still advise that folks that apply for Medicare and Social Security keep copies of that application so that when they go to the Medi-Cal office, they have proof of that just in case it's needed.

So here's an example. Mr. Ko is 67 and enrolled in part B. He has aged and disabled Medi-Cal and his income is 1,160 a month. Mr. Ko has worked part-time jobs for most of his life and does not have the work credits for free part A. So he decided not to apply for premium part A when he turned 65 and does not have Q and B.

I will say that also when someone applies for Medi-Cal, you are supposed to be screened for the Q and B program. So Mr. Koh should have been screened for Q and B when he got on the Aged and Disabled program and was Medicare eligible. I don't think we always see that the counties are screening folks uniformly for like your Aged and Disabled and Q and B. Some counties do, some counties don't.

But so that's why we were also talking about having to apply for QMB, even though the counties really should be screening people when they become Medi-Cal eligible, when they turn 65 onto Medicare or as they go through their renewal processes. But I can't say that that has always happened. So for Mr. Koh, he's only has Part B and the aged and disabled Medi-Cal.

Speaker 1 (44:03.886)

program. He does not have QMB or premium part A. So in January, he learns that Medi-Cal will pay his part A premium. He hears about this QMB program. So he goes to Social Security to apply. But because Social Security does not handle the QMB applications because it's a Medi-Cal program, he's directed to go to the county Medi-Cal office. So he does so and he submits his QMB application on January 5th.

The county reviews it, it's approved in January, and he's enrolled in premium part A.

His application was submitted in January, but by state and federal law, QMB effective date is not the same as your application date. So his QMB effective date is February 1st and so is his Part A, the same month as his QMB. So that means February 1st and ongoing, he will get state payment of his Part A premiums. He is a QMB person and he also has

all of the federal protections against improper billing now apply to him as a QMB.

Here's another example. Mrs. Lee immigrated to California in 2011 at age 57. She came to care for her disabled adult daughter who lived in the U.S. She does not have the work credits for free part A because she was unpaid. She is uninsured and has recently started needing medical care. She does have a part-time job earning $1,100 a month. So Ms. Lee applies for Medi-Cal and is directed to apply for Medicare.

Speaker 1 (45:52.174)

when she turned 65. She cannot afford the monthly Part A premium because she hasn't been in the US long enough to have that 10 years of work history. If she did sign up for Part A with a premium, the premiums alone would take up more than 50 % of her income. Again, she only earns $1,100 a month, so that is not feasible.

She applies for QMB2 but is rejected because she has not established that she is eligible for either Medicare Part A or B. She has gone without any health coverage while she has been here. So what steps does she need to take next?

So first, again, she does not have any sort of Medicare, Part B or Part A. So she has to establish that she even qualifies. So she goes to Social Security and applies for Part B. She is enrolled. And after that, she can apply for QMB. She should keep a copy of her Part B enrollment with Social Security so that she can bring it to the county office.

She is approved for the Q and B and so California is also going to enroll her into premium part A and pay the premium. She did not apply for conditional part A at Social Security and she did not have to. Her part B application was enough. But that does mean she's going to see some delays in her part A effective date because she only applied for part B only after she applies for part A.

for part A and for Q and B with Medi-Cal, will that part A enrollment date start?

Speaker 1 (47:40.942)

So for this group and part a buy in there's also multiple notices that have been sent out. The Q and B approval notice of action will be sent and then Social Security on their end will send folks a notice that they've been enrolled into Medicare and a new Medicare ID card if it's needed.

And then we have the Q &B approval date again.

Sample notice. This is the one that Social Security looks like that says California is going to pay your Part A premiums. This notice says October 2024, because that is the first date that this started. But obviously people that have been applied at a later date will get different notices, a different notice date on theirs. And I don't have a copy of what

the ID, the notice that comes along with someone that gets a new ID card that has not been shared with us, but we do have a copy of at least the notice saying that you have part A.

Speaker 1 (48:52.302)

So key takeaways from all of this, if you're on SSI, it's simple. You are automatically enrolled into both QMB and if needed premium part A. That group should not be asked to submit any application for QMB or part A. If you are hearing otherwise, let me know, because that means education needs to be done or there's some problems. If you don't have SSI,

you will not be automatically apply enrolled into QMB or part A, and you may still need to go to Social Security to apply for Medicare. But if you have part B already, you only have to submit one application, and that's for QMB to get QMB and payment of your part A premiums. And then people that are already enrolled into any of these programs, if you're already in QMB, if you already have part A or part B,

This does not apply to this group, to those groups. All of what I have talked about today are only for people who are on SSI or people who are not yet enrolled into premium part A, but are eligible for state help or state payment of those part A premiums. So if you see problems in any of these areas,

Let me know. Although I don't do direct services, we have a lot of contacts with the local legal aides in each county that do provide those direct services. We can elevate issues to the Medi-Cal office. They did a lot of work on the back end to make sure that the enrollment processes went smoothly. And so far, I've only heard good things. I haven't heard of any hiccups. If you do hear of hiccups though, please let me know because we can.

immediately escalate those and fix issues. Or if you hear of counties that are also giving out incorrect information, we want to hear that as well. It is a new policy. It's pretty complicated. And even, you know, the past two part conditional part a process was already not well known and a lot of incorrect information was given out. So I can only imagine that it may be the case with

Speaker 1 (51:16.878)

the new updated policies, even if they're meant to make things easier.

And then there's some other updates. The Medi-Cal, DHCS, our Department of Health Care Services, they oversee our Medi-Cal health coverage in California. They told us last year that they are looking into increasing the QMB income limit. So this is not set in stone. It is not concrete. I don't have a date when this will happen. And we do need federal approval to do this. One second.

Speaker 1 (51:54.961)

But DHCS is exploring increasing the current limit, which is at 100 % of the federal poverty level to 138 % of the federal poverty level. As you know, Medi-Cal for older adults, the income limit in our Aged and Disabled program is set at 138%. So by increasing the QMB limit to match the Aged and Disabled limit,

we would open up the benefits of QMB to more people, really to help pay for the part eight premiums. That is gonna be the big difference for those people that are low income, but not low income enough that they are at 100 % of the federal poverty level, because that is very low. 1305 a month gross is what 100 % of the federal poverty level is. So this is still ongoing.

The state is evaluating whether to do this, what it would cost. If it happens, we would have to get federal approval and there would be some implementation steps before it would occur. And if we do it, we will put it all over our listserv so you would be notified. And then of course, I'm sure most of you have heard of this, but there are potential funding threats to our Medicaid program in California.

California right now is going through a budget shortfall. And then in the federal government, there are talks to reduce the federal spending. And if the amount of money that California gets from the federal government to fund our Medi-Cal program in California goes through, we anticipate that California will have to make hard decisions and make funding cuts or cut some services in California.

There's been many different expansions. We have increased access to Medi-Cal for undocumented immigrants. We've also increased our income limit for aged and disabled to 138. That is not what it has always been. We have services like IHSS or dental. Those are optional. California is not required to provide those services under federal law, but they do so. They have chosen to do so.

Speaker 1 (54:15.63)

But in past budget deficits, California has rolled back dental to adults. They have cut IHSS hours. So there's a lot that could happen in California if because of any federal funding cuts, it would impact our Medi-Cal program today. So is there a lot of advocacy that is going on to fight against any Medicaid cuts if you are?

signed up for our listserv. There's a lot of opportunities on there to engage in advocacy or just to get up to date news on what's happening.

I have a bunch of resources listed here. When I share the PowerPoint, you'll be able to link those if you're interested. And then anyone is always free to also contact me directly if you have questions about what I covered today or anything else really that is Medicare or Medi-Cal related. We do answer questions from folks like you that work directly with people to try and resolve any issues or connect you to who

who may be able to help you fix certain problems.

Speaker 1 (55:50.19)

So question is, if you have part B and submit an application for QMB to get part A coverage, what happens with your part D coverage? Well, that's a good question. Nothing happens with your part D coverage. That is completely separate. People that are Medicare eligible or have Medicare because they're age 65 or younger but have a disability, once you

Get onto Medicare. Medi-Cal cannot pay for your prescription coverage. Medicare is considered primary. So Medicare will pay for any dual-eligibles Part D prescription coverage. So what I talked about today will not impact someone's access to Part D. They probably already had Part D because Medi-Cal has required that folks...

that are on Medicare or Medicare eligible have already signed up for Part D because they simply are prohibited, Medi-Cal is prohibited from paying for a dual eligible's prescription cost except for in some very rare circumstances, but that's why most, if not all dual eligibles are getting most of their prescription drugs covered under the Medicare Part D program.

So Q and E or the part A applications will not impact someone's part D.

And if that didn't answer your question, feel free.

Speaker 2 (57:45.646)

I'll go ahead and close this out. First of all, thank you all for joining us today. And a huge thank you to Tiffany who actually did simplify such a complicated process. So thank you so much, Tiffany, and your wisdom, your insights and your expertise really shined and I couldn't thank you more than for making it very clear.

I hope this session gave everyone practical ways to better support your Medicare and Medicaid or Medi-Cal patients, specifically when it comes to enrollment and the Part A buy-in. I, As FQHCs, you all play a critical role in closing these coverage gaps and ensuring that the patient has access to care as well as resources. So we're exceptionally thankful that you guys all joined today. We'll be sharing some follow-up materials.

And we encourage you to bring this back to your teams and just start the conversation. Thank you again from all of us at Alcar Health and Justice in Aging. We appreciate the work that you do and we're very grateful to be in partnership with you all. Take care.

Alcar Health

Natascha French — Mon, 11 Mar 2019 07:00:00 GMT

November 21, 2024

By: Alex Carrillo, CEO, Alcar Health

As Alcar Health marks 14 years, I’m proud to reflect on how far we’ve come—and even more excited about where we’re headed. When I first started Alcar Health, it was out of necessity to be my own boss, make my own schedule, and make a good living. But over the years, that changed, and the mission became clear: to help people in a way that truly makes a difference. We now have the privilege of providing solutions to serve low-income communities like the ones I grew up in South Central LA and East LA. This firsthand experience drives how we develop and execute solutions that resonate deeply with our communities.

This vision has guided every decision and partnership we’ve formed and keeps me motivated through the evolving challenges in healthcare. We’ve expanded our services, refined our focus, and embraced new opportunities to support FQHCs in impactful ways. Alcar Health is not just a service provider—we’re subject matter experts, advocates, and partners, ensuring your organization has the right solutions customized to your needs.

Why Alcar Health Is Different

What sets Alcar Health apart is our team and the expertise we bring to every partnership. Our team comprises Latino healthcare leaders who have led FQHCs, tech founders, and entrepreneurs who faced the same challenges and know firsthand the daily pressures they deal with. We’re not just service providers but subject matter experts who develop and execute solutions grounded in real-world experience.

That’s why we approach each partnership with a focus on tailored strategies designed to address your organization’s unique challenges and goals. Our bilingual teams are skilled in Medicare and Medicaid enrollment, patient outreach, contact center augmentation, specialty services, and operational efficiency. We’re not just solving problems but driving solutions that build capacity, ensuring your organization is set up for long-term success.

A Partnership Built on Flexibility and Trust

One of the things I’m most proud of is the flexibility we offer to our partners. At Alcar Health, we don’t believe in rigid contracts or one-size-fits-all solutions. Instead, we collaborate with organizations that share our principles, building customized strategies that adapt as your needs evolve. Our commitment is to provide continuity and control—ensuring that your organization retains the insights and expertise it gains through every partnership.

For FQHCs, this means focusing on what you do best—providing excellent patient care—while we manage the complexities behind the scenes, from bilingual contact center support to patient engagement and specialty service expansion. We advocate on your behalf, helping you maintain operational excellence without increasing internal burdens.

Alcar Health’s Expertise: Tailored to Support FQHCs

Our team has perfected a comprehensive suite of services designed specifically for FQHCs. Whether you want to increase Medicare Advantage enrollment, optimize patient engagement, or enhance behavioral health services, we bring the right tools and experience.

Medicare & Medicaid Enrollment Support: Our bilingual teams streamline enrollment processes, keeping patients connected and within your health center.
Patient Engagement Optimization: We develop strategies to boost patient satisfaction and retention, ensuring patients feel supported and understood.
Telehealth for Behavioral Health: We help you extend culturally competent, bilingual care to underserved populations delivered remotely by our partner licensed professionals.
Operational Efficiency: By augmenting your teams with our bilingual contact center agents, we reduce administrative burdens while improving efficiency and response times.

Looking Ahead: Shaping the Future of Healthcare Together

As we approach our 15th year, I couldn’t be more excited about what lies ahead. Healthcare is evolving, and so isAlcar Health. We’re constantly innovating to support FQHCs in enhancing patient outcomes and expanding access to care. Our goal is to be a long-term partner, navigating the complexities of healthcare together and developing truly impactful solutions. We’re open to collaborating with organizers aligned with our mission, working together to drive real change.

To everyone who has been a part of Alcar Health’s journey so far, thank you. You’ve made this milestone possible, and I’m deeply grateful for your trust in us. Together, we can continue to shape the future of healthcare, making a lasting impact in our communities.

Let’s continue to build something great. Connect with us to explore how Alcar Health’s approach can support your growth, and join us in shaping the future of healthcare in our communities.

Thank you for being part of this incredible journey.

Alex Carrillo

CEO, Alcar Health

Insights

Alcar Health

About the Webinar

Rethinking Medicaid: Turning Data Into Action Before HR1

Key Takeaways

Who Should Watch

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Transcript

Alcar Health

About the Webinar

Alcar Health

Arlette SantiagoChief Administrative Officer, Mexico Division

Alcar Health

About the Webinar

Alcar Health

About the Webinar

Alcar Health

Alcar Health

Arlette Santiago
Chief Administrative Officer, Mexico Division