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Medicare resources for providers
Find information about Medicare compliance requirements, training, enrollment, appeals and more.
Aetna Medicare Advantage plans include HMO, PPO and D-SNP
A D-SNP (Dual Special Needs Plan) provides benefits to Medicare-qualified members who also receive Medicaid benefits and/or assistance with Medicare premiums or Parts A & B cost-sharing. Members must live in a county where Aetna Medicare offers a D-SNP.
Important: Annual Medicare Compliance Program Requirements
New and existing participating providers in our Medicare Advantage (MA), Medicare-Medicaid (MMP), Dual Eligible (D-SNP) 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 D-SNP Model of Care (MOC) training.
Additional Compliance Information
- MA/MMP: Providers who participate only in our MA/MMP plans do not need to complete an annual FDR Attestation.
- MA/ D-SNP/FIDE: Providers who are in states/regions that offer MA/D-SNP/FIDE plans are required to complete an Annual D-SNP Model of Care (MOC) training and attestation.
- Delegated Entities: Provider attestation collection for the FDR compliance requirements continue to be required for Delegated Entities.
Annual notification regarding requirements will be sent to providers via Adobe Acrobat Sign email or postcard. Providers continue to be notified via OfficeLink Newsletters during the summer months. 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)
D-SNP Model of Care training (PDF) – Required only if you are in our D-SNP network
Provider and delegate frequently asked questions (PDF)
Read our Office Manual and/or Newsletters to learn more on Medicare program requirements:
Annual D-SNP MOC Attestation
All Providers participating in D-SNP or FIDE Plans, complete the attestation here:
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 D-SNP/FIDE plans attestation
Have questions on the Medicare Compliance or D-SNP 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:
Dual Eligible Special Needs Plans (D-SNP):
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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 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
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
See State of Connecticut retiree for special handling of Part B drugs
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.
Supplemental retiree coverage and claims processing details (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.
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.
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.