Coordinated Care Incentive FAQs
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Reimbursements and Incentives
In order to be eligible for the Reimbursements and Incentives listed below, you must see an in-network provider.
- EHP Plan network is QA / Cleveland Clinic
- EHP Plus Plan network is QA / Cleveland Clinic and Aetna Select Open Access
- Akron ONA, Main Campus Residents and Fellows plans Tier 1 Network is QA / Cleveland Clinic
- Out of Area and Nevada network is QA / Cleveland Clinic and Aetna Select Open Access
- Cleveland Clinic Weston network is QA / Cleveland Clinic and United Choice Plus for Internal Medicine, Obstetrics, Pediatrics and BH
Caregivers and families residing in states outside of Florida, Ohio and Nevada are not able to participate in Coordinated Care. Health plan members will be directed to participate in either the eCoaching program or use of an Activity Device. Contact Us if you have questions.
When am I eligible for reimbursements and incentives?
1. Members must utilize their EHP Medical and Pharmacy benefit for the services, supplies and medications in order for these items to be eligible for Coordinated Care program copay reimbursement.
2. The Employee Health Plan(s) (EHP) must be the member’s primary insurance.
3. The EHP card holder (insured), spouse and all eligible dependents on the plan must be actively employed at CCHS, or active on the policy, or be on COBRA at the time receipts are submitted for payment to receive any copay reimbursement.
4. Once you enroll in a specific program, the copays for the following screening supplies required for you to manage the chronic condition can be reimbursed. These items may include:
• Diabetic testing supplies and Glucagon, if enrolled in the Diabetes program. (This does not include alcohol wipes or calibrator/control solution.) Not all items are reimbursable. This applies to adults (18 and up).
• Peak flow meter and aero chamber (up to $20.00 for each) and Epinephrine pen if enrolled in the Asthma program. (The disposable mouthpiece for the peak flow meter and the coinsurance for a nebulizer are not reimbursable).
• One (1) upper arm blood pressure monitor if enrolled in the Hypertension program, up to $55.00. No finger or wrist blood pressure monitors will be reimbursed.
• One (1) Bathroom scale (up to $40.00) and one (1) upper arm blood pressure monitor (up to $55.00) if enrolled in the Congestive Heart Failure program. No finger or wrist blood pressure monitors will be reimbursed.
• Reimbursement for peak flow meters, bathroom scales and blood pressure monitors occur once every 5 years.
5. If you are enrolled in the Diabetes program and you have received prior-authorization approval, your insulin pump will be covered at 100%. This applies to members who reside in the state of Ohio and Nevada only.
6. Up to five (5) condition related office visit copayments per calendar year are reimbursable AFTER you have met all the program goals. Copay reimbursements will be paid as of the date the member has been identified as meeting all program goals and must keep meeting all goals to continue to be eligible for the copay reimbursement.
• EHP Members enrolled in the Diabetes program who have met all the program goals are also eligible for reimbursement of additional copayments for one (1) dilated eye exam and one (1) foot exam per year.
• EHP Members enrolled in the Depression program who have met all the program goals are also eligible for copayment reimbursement for up to 15 office visits with a licensed clinical counselor, licensed independent social worker, and/or psychologist.
Receipts must be submitted within six (6) months of the date of service. The receipt should include the patient’s name and date of service. No hand written receipts will be accepted. Release of reimbursement funds is dependent on confirmation that a claim has been paid by the Third-Party Administrator, Aetna or UMR (Florida members).
7. Medication copays for qualifying condition-related prescriptions, syringes, pen tips and needles can be reimbursed 6 months from the date all program goals have been met. This incentive can only be extended if you continue to meet the goals. Your annual EHP Prescription Benefit deducible must be met each year prior to any reimbursement being released. Drug manufacturer coupons used to pay your annual prescription benefit deductible will not be applicable for this reimbursement program; if you used one, the first $200.00 of your medication actually paid by you will be considered non-reimbursable. Receipts must be submitted within six (6) months of the fill date
If you plan on retiring, you must submit all receipts BEFORE the date of retirement.
May I submit testing supply receipts?
Only testing supplies (i.e., test strips and lancets) purchased from Cleveland Clinic Pharmacies, Cleveland Clinic Home Delivery, in network providers for EHP and EHP Plus plans or Tier 1 providers for Akron ONA, Main Campus Residents and Fellows, and Cleveland Clinic Weston plans will be reimbursed. No receipts will be processed for any supplies filled by other pharmacies or providers. CVS/Caremark Mail Order Pharmacies’ or CVS/Caremark Specialty pharmacies’ approved medications or testing supplies are NOT reimbursable unless the policy holder resides in a state outside of Florida and Ohio. Receipts must be submitted within six (6) months of the date of purchase.
Supplies for Insulin Pumps and Continuous Glucose Monitors
• Insulin pumps require prior-authorization according to the EHP Summary Plan Description.
• These items must be obtained through an in-network provider for all EHP plan(s) per network listed above.
• Copays for continuous glucose monitors, transmitter and/or receivers are reimbursable upon meeting all the goals of the Diabetes program and are in compliancy.
• Copays for some of your insulin pump supplies and continuous glucose monitor (device and parts) are reimbursable if you have met all the program goals and are in compliancy.
• The coinsurance is NOT reimbursable for glucometers.
• Copay reimbursements will be paid as of the date the member has been identified as meeting all program goals and must keep meeting all goals to continue to be eligible for the copay reimbursement.
• Not all supplies are reimbursable (e.g., batteries).
• Receipts must be submitted within six (6) months of the medication or DME prescription fill date.
NOTE: If you do not stay active and participate in the Diabetes Coordinated Care program, you will no longer be eligible for copay reimbursement.
If you plan on retiring, you must submit all receipts BEFORE the date of retirement.
Will all of my medications be reimbursed?
No, only medications that are related to the program that you are enrolled in may be eligible for reimbursement. Please be aware that not all medications are on the reimbursable medication list. Your Care Coordinator can discuss which medications are eligible or you may check the pharmacy benefit resources that tell you which are eligible. Reimbursable Medication Lists are located at the bottom of the Employee Health Plan Coordinated Care web page.
You will receive a letter from your EHP Care Coordinator when you are meeting all the goals of the program that will tell you which medications you are currently taking that can be reimbursed. If new medications are ordered or if you have questions about whether a medication is eligible for reimbursement, please review with your EHP Care Coordinator to find out if that medication can also be reimbursed.
PrudentRX
Members on specialty medications that qualify for the PrudentRx specialty medication copay program are not eligible for coordinated care medication reimbursement, as the PrudentRx program will cover the entire cost of their medication after enrollment. If members do not enroll in the PrudentRx program, they will be subject to 30% co-insurance costs for their specialty medication(s) after the annual prescription benefit deductible has been satisfied and these costs are not eligible for coordinated care medication reimbursement.
Your annual pharmacy deductible is waived for generic prescriptions only if they are filled by Cleveland Clinic Pharmacies and/or Cleveland Clinic Home Delivery/ Cleveland Clinic Specialty Pharmacy. Brand name medications are subject to the annual deductible. If a generic medication is available, only the generic medication will be eligible for copay/coinsurance reimbursement, unless you have a prior authorization from the EHP Pharmacy Management department on file that specifically authorizes coverage of the brand name medication at the preferred formulary brand co-insurance. Please refer to your current Prescription Drug Formulary Handbook for lists of brand name and generic medications.
Receipts must be submitted within 6 months of the prescription fill date.
If you plan on retiring, you must submit all receipts BEFORE the date of retirement.
May I submit medication receipts from any pharmacy?
No, only medications that are filled at one of the Cleveland Clinic Pharmacies/Cleveland Clinic Home Delivery/Cleveland Clinic Specialty Pharmacy. No receipts will be processed for any prescriptions filled at any other pharmacy. CVS/Caremark Mail Order Pharmacies’ or CVS/Caremark Specialty Pharmacies’ approved medications are NOT reimbursable unless the policy holder resides in a state outside of Florida and Ohio.
If the EHP member is enrolled in the Coordinated Care program and is eligible for medication and/or testing supplies reimbursement, the member must utilize a Cleveland Clinic Pharmacy or Cleveland Clinic Home Delivery to qualify for medication and/or testing supplies reimbursement. Prescriptions obtained from a non-Cleveland Clinic Pharmacy are not eligible for reimbursement through the Coordinated Care program.
Appropriate documentation must be submitted with the request, which includes both the tax receipt and the entire detailed register receipt. See an example of what to submit at the Employee Health Plan Resources/FAQs web page and scroll down to Coordinated Care – How do I submit a receipt for reimbursement?
Please talk with your EHP Care Coordinator to learn if your medication qualifies for reimbursement.
What documents do I need to send in for reimbursements?
Acceptable forms of documentation required include:
1. Office copay receipts should include the Date of Service. The patient name on the receipts and the provider’s name are preferred but not required. Receipts such as (but not limited to) Epic and Core receipts are acceptable as proof of payment or an itemized statement showing proof of payment.
No hand written receipts will be accepted. The Date of Service must be included on the documentation submitted if the member paid after the visit.
2. Individual tax receipts/bar code receipts, along with the detailed register receipts from the Cleveland Clinic Pharmacies or Cleveland Clinic Home Delivery. Both must be submitted in order to request reimbursement. We do not accept the pharmacy printouts. Examples of the receipts to submit for reimbursement are located on the Employee Health Plan Resources/FAQs web page and scroll down to Coordinated Care – How do I submit a receipt for reimbursement?
3. For DME qualifying medical supplies related to a program, purchased through an in network provider as listed above. You must submit the shipping ticket, invoice, or itemized statement from the DME provider that shows the patient name, date of service, and amount paid along with proof of the type of payment (canceled check or payment receipt for a credit card statement). Both must be present to request reimbursement.
WE CANNOT ACCEPT THE FOLLOWING AS PROOF OF PAYMENT:
a. Explanation of benefits received from Aetna or UMR (Florida Weston members).
b. Cash register receipts by themselves with no identifying information (date of service, and patient name). You must submit the individual tax receipt with the entire detailed register receipt. See an example of what to submit at the Employee Health Plan Resources/FAQs web page and scroll down to Coordinated Care – How do I submit a receipt for reimbursement?
We encourage you to keep a copy of all documentation submitted for your records.
How do I get my reimbursement check?
Reimbursement checks will be mailed to the policy holder’s address as listed in Workday from Aetna or UMR if you belong to the Florida. Please review any mailings received from Aetna or UMR (Florida Weston members).
Your reimbursement check will be on the bottom of a form that looks very similar to the Explanation of Benefits.
Where do I send my receipts for reimbursement?
Documentation needs to be sent to Cleveland Clinic EHP Medical Management. Please remember to include on your cover sheet: the patient’s name and one other individual identifier such as date of birth, and/or the Member ID number.
You have three submission options:
Scan and Email: EHPpharmacyreimbursement@ccf.org
Fax: 216.442.5795 to the Attention of Reimbursements
Mail to: Cleveland Clinic Employee Health Plan
Attn: Coordinated Care Reimbursements
25900 Science Park Drive/Mail Code AC242
Beachwood, Ohio 44122
How long does it take to get my reimbursement check?
Qualifying receipts may take up to 60 days for processing. The claim must be submitted by your provider and paid by Aetna or UMR before any copay reimbursement can be processed. Please contact your Care Coordinator if you have any questions. If your receipt does not qualify for reimbursement, you will be notified.
Who is the reimbursement check made out to?
Reimbursement check is made out to the policy holder of the health plan coverage.
What happens if I lost or didn’t receive my reimbursement check, or I find an old, uncashed one?
EHP, EHP Plus, Akron ONA, or Main Campus Residents and Fellows: Aetna will process member requests to replace never received, lost or misplaced reimbursement checks. It must be over 30 days since issued. The member will need to contact Aetna directly by phone at 833.414.2331.
Cleveland Clinic Weston plan members: UMR will process member requests to replace never received, lost or misplaced reimbursement checks. It must be over 30 days since issued check totaling $20.00 or larger. The member will need to contact their Care Coordinator. There will be a replacement fee of $10.00 deducted from the original reimbursement.
Lost, misplaced or never received checks will not be replaced if it has been more than 180 days* from the date of the original check being issued.
The member is responsible for ensuring that their correct mailing address is on file with the Human Resources Department in Workday.
* Note: Requests for check reissue that are over 180 days from the date the original check was issued will be declined due to the amount of time that has passed, regardless of the original check amount.