Attention EHP Coordinated Care Members
The Third Party Administrator (TPA) transition to Aetna has been completed and while we are pleased with the results and efficiencies we have experienced so far, we have encountered certain challenges impacting copayment reimbursements. Until these issues are resolved, we are holding copay reimbursement payments to members. Please continue to submit your receipts as reimbursements will be processed once the issue is resolved. The EHP website will be updated as we work to fix the issue. Thank you for your patience.
This alert applies to members with Aetna as their Third Party Administrator only and does not apply to the situations below:
- Members in the Florida region who have UMR as their Third Party Administrator will be reimbursed as usual
- Pharmacy copays will be reimbursed as usual
Alert posted March 3, 2022
Infertility Benefit Coverage Alert
Cleveland Clinic Employee Health Plan Infertility Benefit Coverage
Applicable for plan year January 1 through December 31, 2022
Definition of Infertility:
A member is considered infertile if he or she is unable to conceive or produce conception if:
- after 1 year of frequent, unprotected heterosexual sexual intercourse, or
- after 6 months of frequent, unprotected heterosexual sexual intercourse if the female partner is 35 years of age or older
- Alternately, a female without a male partner may be considered infertile if she is unable to conceive or produce conception after at least 12 cycles of donor insemination (6 cycles for females 35 years of age or older)
- For a male without a female partner, after at least 2 abnormal semen analysis taken at least 2 weeks apart
- An individual who self identifies as transgender or whose reproductive partner is transgender can also be considered infertile if one or more of the above definitions of infertility are met
Eligible Health Plan Members must meet the following requirements:
- Enrolled in EHP, EHP Plus, Main Campus Resident/Fellow plan
- Between age 18-50 years and if female be premenopausal and reasonably expect fertility as a natural state; or menopausal and experiencing menopause at a premature age
- Dependent children of plan members are excluded
- Must be a non-smoker/non-tobacco user
- Have had no previous elective sterilization procedure, even if reversed
- Have approval from the EHP Third Party Administrator (TPA) Aetna’s National Infertility Unit (NIU)
- Marymount employees and spouses are subject to Religious Exemption and therefore not eligible
- Medical plan covers up to $15,000 in infertility treatment per lifetime
- Prescription medications covered up to $6,000 per lifetime
- If both the Caregiver and Spouse are Cleveland Clinic employees, the benefit follows the infertile member (the couple cannot access $30,000 medical benefit / $12,000 pharmacy benefit if only one is infertile)
Access to the Benefit:
- Health Plan members will not receive coverage until they initiate a review for infertility treatment. The review process differs by plan. Below please find plan specific contact information to start the review process:
- Aetna members should contact a Aetna Fertility Advocate (FA) at 1.833.415.1709 (8am-4:30pm EST)
- Florida/UMR members should contact UMR Precertification at 1.800.808.4424
Additional details will be available in your plan specific Summary Plan Description (SPD) which will be available by mid-February.
Alert posted February 2, 2022
EHP now covers over-the-counter COVID-19 test costs
Employee Health Plan (EHP) now covers over-the-counter COVID-19 test costs either at the point-of-sale with no up-front cost to the member, or through reimbursement after the purchase is made. This applies to over-the counter (OTC) COVID-19 tests that are FDA Approved under Emergency Use Authorization, and that are purchased on or after Jan 15, 2022.
Reimbursement is permitted for up to eight tests per covered individual over a 30-day period (or per month) (i.e., if each kit contains two tests, then the individual can be reimbursed for no more than four kits in a given month). This is in accordance with the federal guidance regarding at home diagnostic tests or over-the-counter COVID-19 testing.
Effective January 1, 2022, the Employee Health Plan phone number has changed
If you are calling about Healthy Choice, billing, medical plan benefits, the Willis audit, precertification for medical, behavioral health and pharmacy services, and the Coordinated Care programs please call 216.986.1050.