Active

Preserving Access Pilot

Reducing Administrative Barriers for Medi-Cal Enrollment and Redetermination

A multi-sector pilot to determine whether a regional approach to addressing enrollment and redetermination, utilizing a voice AI solution, can effectively address new administrative barriers and preserve access to Medicaid. If successful, spread to other counties in California before the implementation of HR1.

Background

On July 4th, the Federal HR1 was signed into law to reduce Medicaid spending by introducing new federal administrative
barriers designed to reduce enrollment. According to CalHHS, an estimated 3 million Medi-Cal members may lose coverage
due to H.R. 1’s work requirements and an estimated 400,000 Medi-Cal members may lose coverage due to H.R. 1’s
requirements for states to redetermine eligibility for ACA-expansion adults every six months, instead of every 12 months.
This will drive up the uninsured rate and raise costs for hospitals and clinics treating uninsured patients.
According to the California Medical Association, California’s hospitals and physicians are expected to face $9.5 billion in new uncompensated care costs over the next decade, and health system contractions are projected to eliminate 217,000
California health care jobs, reduce economic output by $37 billion, and cut $1.7 billion from state and local tax revenues.
California’s FY 25-26 State Spending Plan includes a freeze on Medi-Cal enrollment for undocumented immigrants aged 19
years and older beginning January 1, 2026, adding further urgency to enrollment efforts with a projected $3.3 billion in
ongoing annual savings as a result of individuals losing health care coverage.

Proposal

The Impact Accelerator recommends adopting technical solutions to quickly reduce administrative barriers for enrollment and
redetermination for Medi-Cal patients across Northern California. It aims to utilize existing, trusted community networks to
support implementation.

HR1 is strategically adding administrative barriers to enrollment and redetermination with the intent of reducing the number of
enrolled lives, regardless of eligibility. This methodology disproportionately affects low-income residents and the safety net
delivery systems serving these patients.

Solution components:

Redetermination support: proactive outreach to patients 6 weeks before the redetermination date to offer support
in the application completion.
Enrollment loss support: proactive monitoring of enrollment loss with active outreach to support application
completion.
Demographic management: updating BenefitsCal with the current address and other demographic informationpresent in the EMR to allow for increased autorenewal completion.

Vendors:

AI Solutions: Voice AI technology supports the completion, submission, and tracking of various benefit applications. It
has been deployed in California and across the U.S. for Medicaid, SNAP, WIC, disability, and TANF, among other
applications, in any language, and accessible at any hour of the day. Thrivelink is a vendor with proven capability and will be among the choices for regional consideration, with other vendors to be considered over time.
Outsourced coverage cycle management solutions deployed at a coalition or county health system to manage coverage
loss. Organizations such as PointCare have been tested in community health centers in Northern California and can be implemented in parallel with AI solutions.

Payment:

To facilitate deployment at scale, the Impact Accelerator recommends that Community Health Center Coalitions
or county health systems hold the contract for all community health Centers in their network, with Managed Care
Organizations (MCO), health centers, funders, or hospital systems collectively paying for the instance.

Data Transfer:

Redetermination, enrollment, and utilization data transfer provided by MCO to coalitions or vendors as
determined by the county implementation plan.

Medi-Cal Application Workflow Redetermination:

Outreach: Outreach to existing patients who require redetermination can be completed via automated phone call, text, or email, white-labeled for the health center organization, or directly from the Managed Care Organization. Patients are offered the ability to complete other applications such as WIC, SNAP, PGE, etc., at the time of outreach.
Escalation: questions and concerns within the application process can be escalated to a vendor staff, health center, coalition/county enrollment counselor, or outsourced coverage cycle management company for support.
Application verification: Patients can opt in to verification of information provided and tracking of the application through a secure portal provided via text.
Application Submission: Completed applications are submitted to the county through BenefitsCal through CBO access.
Tracking: Vendors provide the tracking and notification to the patient and the health care organization.

Medical Coverage Loss Workflow:

Coverage loss monitoring: Vendor monitors coverage loss for a given patient data set.
Outreach: Text or call from the vendor white-labelled for health center or county offering real-time application
support.
Escalation: questions and concerns within the application process can be escalated to the health center, coalition/county enrollment counselor, or CBO for support.
Application Submission: Completed application submitted to BenefitsCal through CBO access.

Phase I: (3 months)

Convening stakeholder networks within each county or health center coalition to create a shared implementation and engagement plan.
Execute contract with Thrivelink, Coalitions, and MCOs.
Establish the scope of work, data sharing agreements, and governance structure.
Finalize measurement scope, plan, and data agreements.
Successful completion of enrollment and redetermination for 50 patients within each participating county.
An outreach plan with community-based trusted messengers was initiated within each county.
Redundancy Coverage Service Management plan initiated within each participating county

Phase II: (6 months)

In-reach and outreach completed for 80% of eligible MediCal enrollees within each county.
Community networks are well-established with a communication and engagement system in place.
Community feedback system in place.
Measurement plan in place with demonstrated ability to analyze meaningful data.
Engagement with DHCS is established to understand work requirements, if available.
Outreach to additional coalitions or counties for spread.

Phase III: (6 months)

Work requirement workflow established and tested, as applicable.
New coalitions and counties enrolled in the pilot with executed Thrivelink contract, funding established, and a community network created.
Measurement and analytics were established with preliminary data analysis completed
Sustainable funding model demonstrated across participating counties.

Stanford and UCSF researchers, in collaboration with other academic partners as needed, will lead the
measurement and evaluation of the pilot. Evaluation considerations:

Redetermination completion rate and cycle time relative to the standard.
Lapse recovery rate at 90 days and 30 days (in preparation for 2027).
Patient experience and ease of completion.
ROI for health plans, health centers, and county systems.
Financial viability of the model and relative cost savings or loss for health centers’ enrollment and coverage.
After-hours completion rates.
Value of the use of networks of stakeholders in the success of implementation and the rate of deployment.
Utilization of primary care, hospital, and emergency room.
Perspectives of patients and health systems on the use of AI as a tool to reduce administrative burden.

Reducing the administrative burden for MediCal enrollment and redetermination is critical to protect health care access for
low-income Californians and for the financial viability of the safety-net system of care.

Creates a multi-sector solution that allows for trust-building and network development across the safety-net and community-based organizations.
Safeguards ambulatory access for eligible patients to reduce liability for overburdened acute care systems.

Our Role

Convene stakeholders and coordinate activities.
Support research and measurement activities.
Project planning and communication.
Network connector, TA support, shared learning across participating organizations and partners.
Fund development.

Stakeholders

MCOs: Partnership Health Plan, Health Plan of San Mateo
Health Center Coalitions: Aliados Health, Community Health Center Network, North Coast Clinic Network
Community-Based Networks: Local CBOs, community leaders, and trusted messengers within participating counties.
Partners: County Human Services (MediCal Enrollment Lead and CHA/CHIP Lead), Health Leads, Safety Net Institute,
Acumen America, DHCS.
Research: Stanford, UCSF