Regulatory & Compliance Q&A: How the OBBBA Could Impact Care Management & Member Engagement

On June 10, 2025, the One Big Beautiful Bill Act (OBBBA), also known as H.R.1, was signed into law, marking the beginning of one of the most sweeping healthcare reforms in recent memory. Given the scope and future impact on regulatory requirements, health plans must closely assess their agility to adapt their business models as well as their digital solutions. Not only must health plans adjust to the increased scrutiny of eligibility validation and expanded scope of government program audits, but also strengthen their adaptability to the downstream impacts of H.R.1 in the years to come.

We sat down with Jennifer Vicknair, RN, MBA, Senior Director of Regulatory, Accreditation and Compliance at HealthEdge®, to discuss how the OBBBA is reshaping state regulations and why regulatory compliance agility is imperative for long-term success.

What are you seeing and hearing so far as the most significant impacts of the OBBBA on health plans?

Vicknair: The most immediate pressure for health plans is changes to Medicaid eligibility validation and waiver programs. Many payers still rely on outdated or highly manual processes and technologies that can’t keep up. Plan leaders are concerned about the rapid pace of change, how to effectively communicate these changes to their internal teams, and the administrative costs of audit readiness.

OBBBA’s impact will exponentially increase complexity at the state level. While the federal laws broadly align regulatory and enforcement governance, each state will respond with specific guidance applicable to their own eligibility rules, benefit structures, and reporting requirements. That means a plan operating across multiple states could be managing an entirely different compliance need in each state. If a plan lacks the technological capabilities to configure benefits and services quickly, the risk of exposure during audits can lead to penalties, sanctions, or exclusions from government programs.

The downstream effects will directly impact the health plan’s quality, population health, and care management programs. Complexity of eligibility and enrollment workflows will necessitate a shift of resources to minimize interruption in coverage. Quality initiatives will lose valuable data points that have been historically used to influence how the plans move the needle on population health. Care management and member engagement solutions play a vital role by giving care teams access to up-to-date information, eligibility, and waiver usage. Real-time information allows care teams to coordinate care effectively, even as regulatory requirements continue to change.

What does “regulatory compliance agility” mean under OBBBA or other such broad changes to healthcare?

Vicknair: Regulatory compliance agility means having prompt regulatory change management. Health plans must partner with technology vendors to operationalize new requirements quickly without months of custom coding. As states issue guidance, audit scrutiny will intensify, and regulatory agencies will begin enforcement activities. Health plans need visibility into their technology ecosystem to proactively address changes, rather than responding retroactively.

Health plans need to partner with technology vendors who provide best-practice workflows and recommended configurations. Technology vendors should support continuous audit readiness by meeting health plan needs for operational controls, traceability, and reporting—and that’s why having integrated care management and member engagement solutions is so valuable.

With HealthEdge GuidingCare® and Wellframe™, health plans can unify clinical data with member engagement. The solutions help surface gaps in care and align clinical resources from health plans and community partners to meet the member’s needs holistically.

It also comes down to partnerships. Technology vendors must demonstrate more than technical capability. Vendors need expertise in Medicare and Medicaid and need to understand the nuance of specific programs like Dual-eligible Special Needs Plans (DSNPs) and Long-Term Services and Supports (LTSS).

A strong technology partner anticipates potential impacts of regulatory change on the health plan and supports the plan’s compliance with appropriate product enhancements. Vendors with strong change management leadership can supplement the efforts of the health plan through cross-functional collaboration. Through strong vendor collaboration, regulatory agility can be the health plan’s ongoing stance for regulatory readiness through implementation and operationalization.

What do you see as the biggest challenges health plans will face as they adapt to OBBBA?

Vicknair: One is the coordination of cross-functional health plan response. Regulations, rules, and guidance often come to health plans sporadically and in dense non-prescriptive language. Translating that into technical requirements or operational workflows isn’t always straightforward. Clinical and care management requirements can be especially vague when considering the expertise required to connect disparate systems and processes to promote quality of care. Resources may be further limited by growing pressure to reduce operational expenses.

Risks of provider disruption and abrasion happen when changes to eligibility and coverage are inconsistent because of near-constant change. For example, if a rural care facility closes, the health plan faces an influx of care coordination, network adequacy, and member access needs. Care management systems like GuidingCare can help by allowing health plan leadership to monitor impacts on population health and track real-time efforts to close gaps in care. At the same time, rural provider disruption reinforces the importance of digital member engagement. Wellframe allows payers to maintain consistent connection between members and care teams. Health plans can provide guidance and support even when local providers may be harder to reach.

Another challenge is OBBBA’s impact on Medicaid funding. Health plans will need to do more with fewer resources. Waiver programs have new budget neutrality requirements which will force plans to demonstrate mechanisms for delivering cost-effective care. Eligibility restrictions will lower federal reimbursement for essential programs that have been proven to improve outcomes. Increased administrative burden coupled with unique needs of Medicaid populations creates risk for compliance, clinical outcomes and population health.

Finally, audit pressure has increased in recent years. OBBBA will refocus regulatory scrutiny because of the expansion of regulatory scope, governance and authority. Regulators are ramping up oversight activities, and health plans that can’t clearly demonstrate compliance with accurate, traceable data and workflows are at risk. Payers need to act now by assessing configurations, documenting workflows, identifying gaps, and validating audit-readiness. Government programs should prioritize avoiding civil and monetary penalties, sanctions, or exclusions—not only to stabilize revenue but to safeguard market growth opportunities.

How should health plans think about technology investments to prepare for OBBBA?

Vicknair: Technology that supports regulatory compliance agility is the priority. Health plans need platforms that support rapid regulatory change management functionality including real-time eligibility validation and clinical outcome tracking. These capabilities reduce compliance risk and lower cost of care.

Integration and interoperability are becoming increasingly important. Most health plans operate in siloed organizational structures and use disconnected systems. OBBBA will encourage plans to coordinate eligibility, clinical, and claims data to enable faster internal decision-making. Affordability and clinical outcome data then become essential for yearly plan benefit design, Model of Care (MOC) submissions and market expansion initiatives.

Finally, payers should look for systems that support population health management. Equipping care teams with tools to assess and manage members at scale allows health plans to address medical and social health risks, close care gaps, and improve outcomes. The health plan’s clinical leadership can then monitor population-specific data to ensure day-to-day work aligns with clinical quality initiatives.

GuidingCare-provides care teams with a comprehensive view of member needs and supports personalized care plans that help members reach their health and wellness goals. The Wellframe also helps care teams foster meaningful connections with members. Together, GuidingCare and Wellframe enable health plans to adapt population health strategies quickly, even in a resource-constrained environment.

How does OBBBA reshape the conversation around population health and member engagement?

Vicknair: Ultimately, OBBBA reinforces the need for cost-effective care through measurable outcomes and validated performance metrics. Health plans must manage members more efficiently. Clinical quality standards coupled with growing value-based care initiatives will strengthen health plans’ need for comprehensive care management. Addressing non-clinical social needs, behavioral health needs, and traditional medical needs will balance reliability of outcomes.

Another significant factor for health plans is the shift in care management caseloads. OBBBA will drastically reduce health plan federally funded reimbursement, which will inherently lead to care teams having a higher nurse-to-member ratio. And, non-clinical care team members will see an expansion in responsibility, as their scope of practice allows. Care teams will have to capitalize on technology efficiencies to positively impact population health outcomes. Scalable member engagement becomes essential.

By offering a mobile app for health plan members, Wellframe ensures engagement is timely, personal, and accessible. Health plans don’t have to wonder if members receive physical mail or wait for pre-scheduled and long-format phone calls to share information. The Wellframe app includes personalized checklists with medication, activity, and appointment reminders. Members can also send direct messages to their care teams through a HIPAA-compliant chat function, and access educational articles that answer common and relevant health questions—empowering members and improving health literacy.

The combination of Wellframe and GuidingCare capabilities supports care teams and members in making better-informed care decisions in less time. Effective population health management is essential for health plan growth post-OBBBA, and health plans should prioritize technology that supports improving medical loss ratios, lowering operational expenses and administrative costs, and protecting reimbursement.

Looking ahead, what advice would you offer to health plans as they prepare?

Vicknair: Don’t wait for perfect clarity. The regulatory landscape will continue to evolve. The best strategy is to invest in technology and vendor partnerships that can adapt to anticipated changes, so payers build agility into their systems and processes proactively.

Take a proactive stance. Educate your teams, model different scenarios, and ensure audit readiness before an audit is imminent. Promote internally that that OBBBA is an opportunity to modernize infrastructure that aligns with government program priorities and allows efficiency gains across the health plan ecosystem.

Are you looking for a strategic framework to help your health plan adjust to rapidly evolving regulations? Read our blog, A Strategic Framework to Navigate the One Big Beautiful Bill Act.