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Quality Management & Improvement Efforts

Quality improvement strategy

We are working hard to improve the service, quality and safety of health care. One way we do this is by measuring how well we and others are doing.

We work with groups of doctors and other health professionals to make health care better.

Our clinical activities and programs are based on proven guidelines.

We give you and your doctors information and tools that may help you make decisions.

Program goals

We aim to:

  • Meet the members’ health care needs
  • Measure, monitor and improve clinical care and quality of service
  • Institute company-wide initiatives to improve the safety of our members and communities
  • Make sure we obey all the rules, whether they come from plan sponsors, federal and state regulators, or accrediting groups

Program scope

We work to make your health care better by:

  • Developing policies and procedures that reflect current standards of clinical practice
  • Reviewing preventive and behavioral health services, and how care is coordinated
  • Addressing racial and ethnic disparities in health care that could negatively impact quality health care
  • Monitoring the effectiveness of our programs
  • Studying the accessibility and availability of our network providers
  • Monitoring the overuse and underuse of services for our Medicare members
  • Performing credentialing and recredentialing activities
  • Assessing member and provider satisfaction

Program outcomes

Each year, we check to see how close we are to meeting our goals. Here's what we did in 2017:

  • We collected data on a set of clinical measures called the Healthcare Effectiveness Data and Information Set (HEDIS®*), as applicable. We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass®.** The NCQA makes the results public. Each year, we use the results to set new goals and improve selected measures. As a result, performance has improved on many measures.
  • We asked members and providers how satisfied they are with Aetna. To improve satisfaction, we:
    • Launched “Service Without Borders” to improve the help and information our Commercial members receive from Customer Service
    • Enhanced the website and online tools
    • Improved the accuracy of our provider directory information 
    • Improved online self-service options for members and providers
  • We surveyed members in the Aetna Case Management program. They told us that the program has helped them better manage their health.1
  • We surveyed members in the Aetna Disease Management program. They told us that their health has improved because of the program.2
  • We also:
    • Improved our patient safety program to help our members make informed health choices
    • Continued using social media to provide information about patient safety
    • Provided patient safety resources to physicians on the secure provider website
    • Provided information on our Hospital Comparison Tool to help members make more informed decisions when selecting a hospital for their medical care

Your behavioral health needs are important to us

As the opioid crisis has continued to escalate, we remain vigilant in taking steps to address this issue. To help prevent addiction, we sent targeted mailings to prescribing providers to encourage appropriate prescribing practices. Mailings are also sent to members and providers to help coordinate care when multiple pain prescriptions involve more than one doctor. We gave grant money to several states to help fight the opioid epidemic at the local level. The Aetna Foundation recently announced $6 million to be given to communities to help fight the opioid crisis. The initial $1 million is targeted at overdose prevention and will be given to the North Carolina Harm Reduction Coalition for a project to provide rural area support. Our Aetna behavioral health clinicians continue to work to identify members at risk for opioid overdose and encourage the use of Naloxone, an emergency rescue medication and commercial member co-pays will be waived.

Additional Aetna Behavioral Health program improvements in 2017 include:

  • Established a monthly behavioral health Patient Safety Workgroup. The workgroup reviews quality of care trends and other patient safety issues. As a result, resolution times of Patient Quality of Care concerns were significantly reduced.
  • Televideo was expanded to all states in January of 2018
  • Designed and implemented an annual survey of our network facilities. Initial results show overall satisfaction with the utilization management process to be 94%

Our plans for 2018:

  • Applied behavior analysis team in place to better assist members in accessing autism services
  • Improve our precertification process for outpatient and inpatient care
  • Clinical Quality Improvement Activities for members with attention deficit hyperactivity disorder, depression and substance abuse diagnoses
  • Encourage broader use of televideo services
  • Continue to focus our efforts to help fight the opioid epidemic


We take our accreditation by the NCQA seriously. It's how we show our commitment to improving your quality of care, access to care and member satisfaction.

*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
**Quality Compass is a registered trademark of NCQA.
1Based on results from the 2017 Aetna Case Management Member Satisfaction Analysis.
2Based on results from the 2017 Aetna Disease Management Member Satisfaction Analysis.


Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Aetna Medicare’s pharmacy network includes limited lower cost, preferred pharmacies in: Urban Mississippi, Rural Missouri, Rural Arkansas, Rural Oklahoma, Rural Kansas, Rural Iowa, Rural Minnesota, Rural Montana, Rural Nebraska, Rural North Dakota, Rural South Dakota, Rural Wyoming. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use.

For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, members please call the number on your ID card, non-members please call 1-855-338-7027 (TTY: 711) or consult the online pharmacy directory at

Participating physicians, hospitals and other health care providers are independent contractors. They're neither agents nor employees of Aetna. The availability of any particular provider can't be guaranteed. Provider network make-up is subject to change. 

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  • If you will be a member with us starting on 1/1/2019 (new and/or existing members), you can access your billing portal on 12/1/2018 at