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    Information and resources for health care providers.

    Reminder: Aetna’s Medicare Advantage plans include HMO, PPO and Dual Eligible Special Needs Plans (D-SNP).

    A D-SNP is a special type of Medicare Advantage Plan that provides benefits to members who qualify for Medicare and are receiving full Medicaid benefits and/or assistance with Medicare premiums or Medicare Parts A & B cost sharing through one of the Medicare Savings Program categories. Members must reside in a county where Aetna Medicare offers a D-SNP.

    Important: Annual Medicare Compliance Program Requirements



    Participating providers in our Medicare Advantage (MA), Medicare-Medicaid (MMP), Dual Eligible (DSNP) or Fully Integrated (FIDE) Special Needs Plans are required to meet the Centers for Medicare & Medicaid Services (CMS) compliance program requirements for first-tier, downstream and related entities (FDR) as identified in the Medicare compliance FDR program guide and/or DSNP Model of Care (MOC) training.

     

     

    New for 2021

     

    • MA/MMP: Providers who participate only in our MA/MMP plans no longer need to complete an annual FDR Attestation. 
    • MA/ DSNP/FIDE: Providers who are located in states/regions that offer MA/DSNP/FIDE plans continue to be required to complete the Annual DSNP Model of Care (MOC) training  and attestation. 
    • Delegated Entities: Provider attestation collection for the FDR compliance requirements continue to be required for Delegated Entities.  Delegated entities will receive their attestation directly through Adobe Sign. Completion of the DSNP MOC training and the related attestation is still required.

    Notification regarding requirements will be sent directly to providers via Adobe Sign email, postcard or you can access the training and attestation at the link(s) below. Our Compliance Department completes random audits to ensure compliance on an annual basis.

    Review Compliance Training(s):

    Proactively review our training resources to ensure you’re in compliance:

    Medicare compliance FDR program guide (PDF)

    DSNP Model of Care (MOC) – Required only if you are in our DSNP network (PDF)

    Provider and delegate frequently asked questions (PDF)

     

    Read our Office Manual and/or Newsletters to learn more on Medicare program requirements:

    Office Manual (PDF)

    FDR Compliance Newsletters

    OfficeLink Newsletters

    2021 DSNP MOC Attestation

    All Providers participating in DSNP or FIDE Plans, complete the attestation here:

    DSNP/FIDE Attestation

     

    Delegated provider / entity Attestation (only)

    Delegated provider/entity: Is contracted with Aetna to perform specific delegated function(s) for example, credentialing or utilization management, etc.

    Delegated provider/entity is required to attest based on contracted plan(s).

    Delegated provider/entity participating in MA/MMP plan(s) attestation

    Delegated provider/entity participating in MA/MMP and/or DSNP/FIDE plans attestation

    Have questions on the Medicare Compliance or DSNP Programs? Review the provider and delegate frequently asked questions (PDF) for more information and contacts.

    Medicare and Dual Special Needs Plans expansion information and resources

    INDIVIDUAL MEDICARE:

    GROUP MEDICARE:

    DUAL ELIGIBLE SPECIAL NEEDS PLANS (D-SNP):

    Join our Medicare Advantage Quality Incentive Program

    Join our Medicare Advantage Quality Incentive Program

    This program includes ways to promote early detection and assessment of chronic conditions. You'll provide the care your patients need, while earning incentives. You can participate if you are a primary care physician with 50 to 749 attributed Aetna Medicare Advantage members and are not participating in another Aetna/Coventry value-based contract or program.

    Part D prescriber enrollment requirement

    Part D prescriber enrollment requirement

    Any health care professional who prescribes drugs to patients with Part D plans must now enroll in the Medicare program or opt out. If you do not enroll or opt out, Medicare Part D may no longer cover these drugs as of February 1, 2017. Please try to enroll or opt out by November 1, 2016. This will allow time for application processing and ensure that patients get their prescriptions without disruption.

    Medicare appeals information

    Find what you need to know about submitting a dispute or appealing a decision.
     

    Learn about the dispute process

    Medicare appeals for non-participating providers

    Appealing a Medicare hospital discharge

    Determining Medicare coverage

    The Centers for Medicare & Medicaid Services sometimes makes changes to coverage rules. See updated National Coverage Determinations (NCDs) that may affect patient coverage.
     

    See National Coverage Determinations


    See Aetna Part B Step Therapy criteria

    Supplemental retiree medical coverage

    The Aetna Supplemental Retiree Medical Plan is a fully insured, non-network-based commercial retiree group health product. In all states but Florida and Minnesota, it is offered as a supplementary medical plan, not a Medicare plan. In Florida and Minnesota, it is approved as a group Medicare Supplement product.


    This coverage is offered only to retirees and their eligible dependents who are enrolled in Medicare.


    Get claims processing information and other details about this plan (PDF)

    For non-participating Aetna Medicare PPO providers

    For non-participating Aetna Medicare PPO providers

    We are expecting an increase in membership for our Medicare Advantage preferred provider organizations. You are likely to see more patients with these health plans.

    Part D pharmacy participation

    We welcome pharmacies to the Aetna Medicare Part D pharmacy network. The network includes retail and non­retail pharmacies, both independent and chain.


    Learn how to participate in our Part D network

    Transition of coverage for Part D

    Members who are taking Part D drugs that are not on the plan's formulary, or that are subject to utilization management requirements, can get a transition supply of their drug under certain circumstances. They can work with you to complete a successful transition and avoid disruption in treatment.


    More about the Part D transition process (PDF)

    Prescription drug coverage

    Find formularies, prior authorization criteria and step-therapy criteria for our Medicare prescription drug plans.


    Find prescription drug information


    Find Part D prescription drug prior authorization and exception forms

    Legal notices

    Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

    Health benefits and health insurance plans contain exclusions and limitations.