HR1 is About to Double Your Medicaid Churn - Here's the Plan

By Jill Steeley, founder of Steeley Strategic Solutions and host of The Community Health Collective podcast. I'm a former FQHC CEO - I inherited an $800K deficit and turned it around - and I help health center leaders build organizations that are financially sustainable and mission-driven.

Highlights:

• HR1 is in implementation now, and its biggest threat is administrative churn, not true ineligibility

• Four dated changes are coming - redeterminations, work requirements, immigrant eligibility, and a shrinking retroactive window

• The reframe that matters: your enrollment team is now your retention team

• A large share of "lost" self-pay revenue is still recoverable, because Medicaid is a moving target

• The plan isn't to cut - it's to protect coverage and capture revenue you already earned

Is HR1 really going to make Medicaid billing harder?

Yes - and it already is. HR1, the law also called the "One Big Beautiful Bill," is in implementation right now, not off in some hypothetical future. But here's the part I need you to hear clearly, because it changes how you prepare: HR1 is not mainly going to make your patients ineligible. It's going to make them lose coverage over paperwork.

Missed mail. Missed deadlines. Applications that don't go in on time or correctly. That's the real risk. And it's about to happen twice as often as it used to.

I brought Howard Archer, CEO of Fix Healthcare Technology and the creator of RetroCAID, back on the podcast to walk through exactly what's coming. This is the plain-language version.

What are the HR1 changes, and when do they hit?

There are four dates worth writing on the wall:

1. Six-month redeterminations. Starting January 1, 2027, expansion adults - roughly ages 19 to 64 - get redetermined every six months instead of once a year. That's double the number of times someone has to renew, which means double the chances they lose coverage by missing a deadline.

2. 80-hour work requirements. Adults will need to document 80 hours a month of work, training, education, or community service, verified at application and at renewal. States have to go-live by January 1, 2027.

3. Narrowing immigrant eligibility. Starting October 1, 2026, whole categories of legally-present immigrants lose access to federally funded Medicaid.

4. A shrinking retroactive coverage window. This is the one almost nobody's talking about. Right now, when a patient starts a Medicaid application, coverage can reach back 90 days to cover services from before they were approved. On January 1, that window shrinks - down to 30 days for expansion adults and 60 days for traditional Medicaid and CHIP. Many states had already trimmed the federal window on their own, but this makes it worse.

Why is this worse than the PHE unwinding?

Because the unwinding was a singular event. When the public health emergency ended, about 4 million people lost Medicaid - painful, but it was one wave.

What's coming with HR1 is more like Groundhog Day. Two renewal cycles a year, every year, patients cycling on and off coverage as they lose jobs, gain jobs, move, and miss mail. The churn we already deal with doesn't just continue - it multiplies.

What problems does this create for a health center?

Here are the problems, plainly:

1. More coverage lapses. Twice the redeterminations means twice the opportunities for a patient to fall off over paperwork.

2. More denied claims. When a patient loses Medicaid over a filing error and you still have that payer on file, you bill it and it gets denied.

3. A shorter runway to recover older visits. With the retroactive window shrinking, you have far less time to capture services delivered before a patient's coverage was approved.

4. Revenue you already earned, now written off. A patient shows up without active coverage, so you bill them self-pay. Later they become eligible - but if nobody's watching, that recoverable claim just sits there until timely filing closes.

What's the plan to get ahead of it?

Here's my take: the answer is not to cut. When you cut services, staff, and sites, you cut your revenue generators and risk a downward spiral. Instead:

1. Turn your enrollment team into your retention team. Keeping patients covered is now a core revenue function, not an outreach afterthought. Some centers are training front-desk staff specifically for the new redetermination and work-requirement maze. Some are hiring for it.

2. Get patients to start their application fast. The start date is the trigger that locks in the retroactive look-back. They don't have to finish it that day - but the clock starts when they begin. With a shorter window, speed is everything.

3. Capture the revenue that's already yours. This is the piece most centers are missing. I used to assume recovering old self-pay revenue was about catching front-desk mistakes. It isn't. Howard's team built RetroCAID assuming the front desk did everything right. The real issue is that Medicaid is a living, moving profile - coverage turns on and off, payers get added months later, benefit packages change - and those shifts turn old self-pay visits into billable claims. RetroCAID monitors that profile daily, for every encounter on a rolling 365 day calendar, and alerts your team the moment an old visit becomes billable. The health centers I've referred are recovering $9,000 to $35,000 a month this way, on encounters some of which are nearly a year old. RetroCaid is purely contingency-based - they only get paid when you collect - and there's no EHR integration, because it works through your state Medicaid office.

The Bottom Line

This doesn't have to be the nail in the coffin for your health center. We know the dates. We can plan for them. The difference between the centers that panic and the ones that get ahead of this isn't budget or size - it's whether someone decided, early, to protect the coverage and capture the revenue that was already theirs.

You're not doing this alone.

🎧 Listen to the full episode with Howard Archer on The Community Health Collective, and if you want help building your HR1 plan, schedule a call with me.

🗓️ Schedule a call with Howard Archer and hear how RetroCaid can help your health center recover Medicaid revenue that you have already earned, but haven’t collected. 

About the Author

Jill Steeley is the host of the Community Health Collective Podcast and an executive coach to leaders across community health centers, FQHCs, and mission-driven healthcare organizations. After two decades inside the healthcare leadership world and close to 250 healthcare leaders coached and mentored, she helps healthcare executives build the leadership skills they were never formally taught - and helps full leadership teams shift culture together rather than one leader at a time.

Learn more at jillsteeley.com.