Medical Management

Versatility and innovation are vital to managing today’s complex medical environment. Aetna Medicaid’s medical management uses both to help health plans administer care resources, giving members appropriate and cost-effective benefits to improve their health.

Our Medical Management team:

  • Ensures disease and care management, as well as pharmacy management
  • Strives to reduce the overuse and underuse of medical service
  • Develops disease management programs appropriate for the populations we serve, including diabetes, asthma, chronic obstructive pulmonary disease and congestive heart failure
  • Profiles providers, including medical services and pharmacy utilization
  • Studies and improves systems and processes related to the provision of health care and services in health plans and health care organizations
  • Minimizes variations in practice by monitoring appropriateness, quality, effectiveness and accessibility of care
  • Monitors and reviews clinical quality indicators, including Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Improvement System for Managed Care (QISMC)
  • Provides prior authorizations for medically necessary or medically appropriate care
  • Conducts concurrent and retrospective reviews
  • Conducts provider and member surveys
  • Credentials and re-credentials providers

Our integrated care management program strives to improve health outcomes while controlling costs. Integrated care management is a collaborative process of assessing, planning, facilitating and advocating for options and services to meet a member’s health needs. This is done through communication and resources across multiple care platforms.  

Our model is designed to improve members’ health care outcomes and to reduce overall health care costs. We do this by making sure our members have access to health care services and that they use those appropriately. We identify members with the greatest opportunity for improvement and match them to the level of care management services they need. From there, we provide them with appropriate, individualized interventions and support.

Helping members take charge of their health
Members who are considered at high risk get the one-on-one support of care managers. Care managers assist with care transitions, care plans and provide self-care education. They also direct members to the right services, information and programs to help avoid unnecessary hospital stays and repeat services.

Through integrated care management, members:

  • Learn about their chronic conditions
  • Become empowered to take an active role in self-managing their conditions
  • Engage their family and caregivers in the management of their chronic conditions
  • Improve their health outcomes and quality of life
  • Decrease health care costs through fewer inpatient admissions and emergency room visits
  • See their whole person by integrating their behavioral and physical health care

Innovative, proactive approach to care
We reflect the strengths, needs and preferences of our members in the care we deliver. We integrate and adapt tools to provide them the right support. This includes care planning, various methods of service delivery, and physical, behavioral and social services. The result is that each of our members gets a strengths-based customized approach.

Interventions and support for better health

Consolidated Outreach and Risk Evaluation (CORE) is a key feature used in integrated care management. It helps to identify high-risk members by medical, social and behavioral factors, not simply by diagnosis. We assign clinical care managers to the most vulnerable members for motivation, support and help with getting the right services.

We improve the member experience with:

  • Reminders to make and keep appointments, and fill and refill prescriptions
  • Goal setting, tracking and motivation to move from smaller, easier goals to harder ones
  • Ongoing monitoring and surveillance to help members stick to treatment, find early signs and symptoms, seek intervention and avoid complications
  • Education, information and tips through our disease management programs to help members improve self-management skills for asthma, depression, diabetes and congestive heart failure

Our disease management programs help members stay healthy. Members learn about their diseases and how to stay well by working with their provider. Our program includes regular communications, targeted outreach and support, and focused education.

The conditions in our program include diabetes, asthma, chronic obstructive pulmonary disease and congestive heart failure, among others.

If you want to know more about our disease management programs, please call us at 1-866-642-1579 or hearing impaired TTY/TDD 602-659-1144. We are here:

Arizona Time 6 a.m. to 8 p.m.
Eastern Standard Time 8 a.m. to 10 p.m.
Central Standard Time 7 a.m. to 9 p.m.
Mountain Standard Time 6 a.m. to 8 p.m.
Pacific Standard Time 5 a.m. to 7 p.m.


Utilization management supports Aetna Medicaid’s health plans by evaluating medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities according to health plan benefits. This also is sometimes called “utilization review.”

Aetna Medicaid’s Long Term Services and Supports program helps aging and disabled members get person-centered health services in their home, assisted-living facility or other setting. Our goal is to keep members within the community. We give members support for daily living and access to quality health care services, including non-Medicaid services and community resources/referral networks.

Aetna Medicaid has a record of success coordinating services for members with complex needs. We provide services using specially designed care models. This includes patient-centered medical homes, health homes and long-term care solutions. We work with providers to make sure that high-quality care is delivered in the most cost-effective way.

We meet members where they are to improve health
Our program values keeping members in the least restrictive care settings. Here’s how we do it:

  • Care management: Our care coordinators meet directly with members to help arrange for all services.
  • Collaboration: We team with providers, hospitals, local organizations and regulatory agencies to improve service delivery and care coordination.
  • Incentives: We offer providers incentives, innovative payment models and added revenue opportunities. This includes a pay-for-performance program.
  • Cost savings: Medically complex members present a chance to improve health and reduce use of high-cost services. Our care management model empowers these members to set their own health goals. We work with members, providers and caregivers to help them reach those goals.
  • Experience: Aetna Medicaid has a long history of putting members’ needs first. We work with providers and local groups to meet those needs. We use a person-centered approach with members who need long term services and supports.
  • Health information exchange: Our predictive modeling tools identify members at high risk for negative health outcomes. Our integrated data systems help members get complete, high-quality care. Our providers use our technology for better point-of-care decision making.

Home- and community-based care
Home- and community-based care services help keep members independent and living in their own homes or in community settings. A care manager works with the member and the member’s family to find the right types of service. This includes the type, amount and length of services. Not all services will be right for everyone. Once these services are agreed to, the care manager will help to arrange them.

Self-directed care
Self-directed services benefit members who have significant disabilities and are working toward living independently. Members work with their care management team to develop a care plan that helps with their activities of daily living. These include support services such as personal care or meal deliveries that keep members independent and living in their own homes.

Preventive care
Prevention is key. To help our members stay healthy, we provide them:

  • An individualized care plan
  • A case manager (depending on state requirements)
  • Frequent and proactive primary care visits
  • Access to weekend and after-hours care coordination
  • Help with transitions across care settings

Aetna Medicaid's Patient Centered Medical Home (PCMH) program puts members at the center of all their health care decisions. This helps to eliminate fragmentation when members cross care settings. It gives members access to a quality-driven interdisciplinary approach to care that uses an entire clinician-led team.

The PCMH model is crucial to transform our health system. Aetna Medicaid’s PCMH program works with providers to help them adopt a new way to deliver care. Our program is part of a larger effort that boosts communication and coordination among providers. It supports members at high risk with effective care management methods.

Aetna Medicaid’s PCMH program transforms health care delivery through:

  • Collaboration
  • Incentives
  • Health information sharing
  • Care management

Our PCMH program features advanced, yet user-friendly technology. Our tools ease the delivery of health services. We help providers identify members at high risk, analyze their needs and make evidence-based, point-of-care treatment decisions. Members get tools that educate and engage them in their care.

We offer secure access to timely data and allow network providers to share information. With these efficiencies, our program helps to prevent costly repeat services and avoidable hospital stays.

Our behavioral health program supports a holistic, member-centered, integrated recovery model of care. We match members with the resources they need to improve their health and to sustain those improvements over time. 

Recovery is one of the fundamental principles our program strives to achieve. It is a process of change. Members work to improve their health and wellbeing, manage their care and strive to achieve their goals. 

Following the recommendations of the Recovery Support Strategic Initiative, Substance Abuse and Mental Health Services Administration's (SAMHSA's), we work with members to help them:

  • Improve their physical and emotional health by developing strategies that overcome or manage their disease
  • Create a stable and safe living environment
  • Bring meaningful purpose to their daily activities including work, school and leisure time
  • Build relationships and social networks that provide support, friendship, love and hope