In October 2024, the California Association of Health Plans (CAHP) hosted its 38th Annual Conference in Palm Desert, California. Over 1,000 healthcare professionals attended to learn how health plans in California are dealing with changes and taking on new responsibilities for the state, navigating laws and regulations, and planning for the future.
Our Payor Services team attended to connect with healthcare leaders and learn the latest updates from a state that often pioneers policies and programs later adopted across the United States. Below, we share key takeaways from some of the conference’s sessions that may impact health plans in California and beyond.
Health Plans Face an Increasingly Complex Regulatory Environment
Health plans at the national level faced a busy year, navigating myriad federal rules and program requirements. Meanwhile, CMS and other federal agencies were busy issuing guidance and rules affecting health plans, such as the federal Medicaid access rules that address managed care access, finance, quality, and access to home- and community-based services.
One session delved into the significant challenges facing health plans nationwide, examining how federal policymakers address these issues and how their decisions are being implemented at the state level. Health plans must closely monitor the evolving regulatory environment and the implications for their organizations.
As Enrollment Rises, So Does Risk
Since 2012, the number of uninsured Californians has decreased from 6.5 million to 2.5 million, echoing similar trends across the country. The rise in enrollment and the growth of health plans over the last decade led to more complex interactions within managed care. As coverage expanded, health plans faced increased scrutiny and challenges.
For example, health plans had to manage a significant volume of provider disputes and member grievances, defend against private litigation, and manage investigations and enforcement actions by governmental regulators at the state and federal levels. To proactively anticipate and respond to these challenges, health plans should consider their compliance and regulatory affairs leaders as integral partners and incorporate their expertise into organization-wide strategic planning.
Innovative Medi-Cal & Covered California Programs Are Expanding & Improving Access
Leaders from the California Department of Health Care Services (DHCS) and Covered California shared updates on initiatives and programs underway in 2024 and previewed what to expect in 2025. In California, DHCS is the single state agency responsible for financing and administering the state's Medicaid program, Medi-Cal, which provides healthcare services to low-income persons and families who meet defined eligibility requirements.
In 2024, DHCS implemented several initiatives affecting the state’s Medi-Cal program, including the continued rollout of the CalAIM initiative, expanding access to Enhanced Care Management (ECM) and Community Supports. In addition, DHCS is implementing the “Justice Involved Initiative,” a pioneering effort allowing eligible incarcerated Californians to enroll in Medi-Cal and receive targeted services 90 days before their release.
DHCS is also focused on key behavioral health initiatives, such as BH-CONNECT, which expands community-based behavioral health services for Medi-Cal members with significant behavioral health needs, and Proposition 1, which aims to modernize the behavioral health delivery system, improve accountability and transparency, and increase the capacity of behavioral health care facilities for Californians.
Covered California experienced a record-high number of enrollments in 2024. Nearly 1.8 million people enrolled, including over 300,000 new enrollees. Starting in November, Covered California will expand coverage to recipients of Deferred Action for Childhood Arrivals (DACA) under a new federal rule change, and the California enhanced cost-sharing program will become available to all enrollees, offering increased affordability.
Moreover, 150,000 new consumers entered the marketplace due to the redetermination process, highlighting the strong connection between the state’s Medi-Cal program and Covered California. The Quality Transformation Initiative is also in full implementation, with updates on health plan performance in its inaugural year and upcoming Population Health Investments funded by collected monies.
As California continues to evaluate the results of these programs and initiatives, many states across the country will likely look to them as examples for their initiatives focused on expanding access.
Health Plans & Hospitals Must Collaborate to Improve the Discharge Process
Under federal and state laws, health plans must comply with timely access rules, claims payment, and utilization management requirements. Hospitals, on the other hand, must meet patient discharge requirements, which include finding appropriate discharge locations, having an effective discharge planning process, and assisting patients and their families in selecting post-acute care providers. The discharge process is crucial and often complex.
While the roles and responsibilities of health plans and hospitals differ, coordination is ideal for enhancing the discharge process. Discharge becomes more challenging for patients needing specialized care, such as placement in skilled nursing facilities (SNFs). Addressing this issue requires attention and solutions, such as increasing the number of available beds or raising government reimbursement rates for SNFs. Health plans must continue exploring new approaches to collaborate with hospitals and improve the enrollees’ discharge process and outcomes.
Our Payor Services Team Can Help
In today's ever-changing healthcare landscape, payors face unique opportunities and challenges. Drawing on deep industry experience and knowledge of the latest updates at the state and national levels, we can help guide payors through end-to-end regulatory reviews, effective compliance functions, improved clinical and quality outcomes, network expansion, reimbursement transformation, and operational compliance and process improvements. We serve national and local payors, including managed Medicare and Medicaid, public and private exchanges, state agencies, and commercial plans.
If you would like to learn more about our services, please reach out to a professional at Forvis Mazars.