Another day, another downcoding policy to grapple with. And while that’s unfortunately the reality in today’s healthcare world, the latest news from Aetna isn’t all bad. The payer has issued a new downcoding policy, but swiftly relaxed it and pushed back the implementation date.

Check out the essentials you must know to prepare for Aetna’s Medicare Advantage downcoding policy.

Aetna’s Original Intent: Downgrading “Low-Severity” Inpatient Stays

When Aetna originally rolled out its downcoding policy in early 2025, the Medicare Advantage payer said it would develop a new model of inpatient reimbursement that applied exclusively to “low severity” inpatient stays. The rates for these visits would be similar to what Aetna was reimbursing for observation visits. The payer said at the time that this would replace its prior policy of simply denying inpatient visits that didn’t appear to be medically necessary, providing at least some pay instead of outright denials.

One sticking point that many organizations had with this policy was that providers and patients wouldn’t have the ability to appeal the downgrades, since denials are more easily appealable. This policy was supposed to take effect on November 15, 2025.

Aetna’s Pivot

On November 6, Aetna released an updated policy stating that the policy won’t be implemented until January 1, 2026, pushing the implementation date back by almost two months. In addition, the payer said the policy will now only apply to emergent or urgent inpatient stays of at least one midnight, but fewer than five midnights.

“Stays of five midnights or greater will not be subject to level of severity review, and will be paid at the inpatient DRG rate,” Aetna said. “For inpatient stays of at least one midnight but less than five midnights that do not meet Milliman Care Guidelines (MCG) criteria, providers may request a severity review and engage in a severity discussion with an Aetna medical director.”

Best practice: If you see Medicare Advantage patients insured with Aetna who are admitted to the hospital, keep the new policy in mind moving forward. If you are subject to a level of severity review, contact Aetna right away and request a severity discussion.