elderly, man, doctor,

A look at the future of Medicaid: Q&A with Pamela Sedmak

Jul 16 2014

The Affordable Care Act has led to many changes that impact government programs, which in turn has led to some confusion about the future of Medicaid and best models of care. As Aetna prepared to participate in a keynote event during the Government Healthcare Congress, we sat down with Pamela Sedmak, president of Aetna Medicaid, for some clarity on these issues.

Pam Sedmak is Aetna's Senior Vice President of Medicaid

Q: The Affordable Care Act expanded Medicaid coverage for millions of Americans. Can you give us a sense of how expansion is going?

A: To date, 24 states are expanding Medicaid, including 9 of our footprint states, enabling 6.5 million new eligibles to have access to coverage, which we fully support. If all 50 states expanded Medicaid, 17 million total eligibles would have access to coverage. In the states that are expanding Medicaid, the greatest challenge is outreach and education. Because these new enrollees have been outside of the health care system, we must ensure they know where to go for care and understand how to use the coverage they have. We are working to educate new enrollees by building strong partnerships in our communities with health care providers and community-based organizations. By working together with our members, their families and caregivers, we are able to have a strong impact on the health and quality of life of our members. This is an exciting time in Medicaid in this country. There are significant opportunities to provide access to health care for people who have been outside the health care system for too long. 

Q: Do you think eventually all states will expand Medicaid?

A:  Given all of the political and budget implications surrounding Medicaid expansion, I would not make any assumptions. However, there is a strong financial incentive for states to move forward; a true need to provide health coverage for expansion beneficiaries; and a need to support the provider community by expanding coverage to those who otherwise would receive uncompensated care. We are prepared and ready to work with and support our state partners who choose to move forward and expand their Medicaid populations.

Q: The Affordable Care Act has also led to new ways of thinking about how we can best serve those who need the most care, and therefore have the highest health care costs. This includes several demonstrations to serve “dual eligibles.” Who are the dual eligibles and what is Aetna doing to help them?

A: Dual eligibles are people who qualify for both Medicare and Medicaid coverage. This population is often the most vulnerable and has many behavioral, social, cultural and physical issues. In addition, there is currently no coordination of care between Medicaid and Medicare, and beneficiaries are left on their own to navigate between two complex programs.

Aetna is participating in four state demonstrations, two of which are launching in 2014. Our demonstrations will integrate the care and management of all of these aspects into a single, unified approach for each individual. We call this a “Duals Model of Care.” The model provides a path for our members to stay with the same plan, have one ID card, one place to call and have the same care coordinators, allowing for a smooth transition at every point of care. This has been valuable to our members as they learn about the program, and we are very optimistic about what we are seeing so far. 

Q: There has been a lot of focus lately about how the behavioral health needs of the Medicaid population can be served. Can you tell us more about that?

A: We have always believed that it is critically important to integrate behavioral and physical health services for Medicaid beneficiaries and have been an industry leader in truly integrating care in an interdisciplinary way on behalf of the member, no matter how they access the health care delivery system. This integrated approach is now a growing focus area for the industry at large. We are working on many exciting programs now to integrate behavioral and physical health care. In fact, we recently launched the Regional Behavioral Health Authority in Maricopa County in Arizona, called Mercy Maricopa Integrated Care. For the first time ever, Mercy Maricopa is integrating the physical and behavioral health needs for members diagnosed with severe mental illness. Aetna Medicaid is working with Dignity Health, Carondelet Health Network, Mercy Care Plan and Maricopa Integrated Health System, sponsors of Mercy Maricopa, to administer and manage the new plan. We are learning a great deal through this program about addressing the behavioral health needs of those served by Medicaid. We believe this insight will be a key to improving the long-term health and well-being of this population.


Related Content:

Aetna and the Duals

Nationally, more than 9 million seniors and people with disabilities are dually-eligible for both Medicaid and Medicare. Aetna is currently working with four states to launch integrated managed care programs to serve dual eligibles, creating new approaches to coordinate care, enhance quality of and access to care, and provide a more simplified member experience.

Aetna is participating with the following State partners in launching these new industry programs:

  • Illinois: Voluntary enrollment in the state ran March 1 to May 31, 2014. Passive enrollment commenced June 1, 2014 and will continue through the end of 2014.
  • Ohio:  Members were invited to choose a plan for Medicaid in April and May of 2014; if they did not choose a plan, the State auto-assigned them. Members are able to voluntarily enroll into the Medicare program throughout 2014. Currently, the State plans to have members who have not chosen a Medicare option passively enrolled into the Medicare plan that aligns with their Medicaid plan on January 1, 2015.
  • New York: The current timeline for voluntary enrollment kicks off January 1, 2015, followed by a passive enrollment period that is expected to begin on April 1, 2015.
  • Michigan: The state currently is expecting to launch its voluntary enrollment in the first quarter of 2015. The roll-out is a phased approach, with members allowed to opt-in, followed by a passive enrollment period that currently is scheduled to launch sometime mid-year in 2015.