Frequently Asked Questions

Healthcare costs nationwide are rising quickly; even with excellent management, our EHP is impacted.
To sustain the health plan's value long-term, modest adjustments are required. Even adding a new medical dedcutible and increasing the premium, Cleveland Clinic is in the 90th percentile of plan "richness" when comparing ourselves to other large employers. We are still offering members a market-leading health benefit.
Each year, Cleveland Clinic invests more than $800 million to keep premiums low and benefits strong for all of us. That is not changing. 

A deductible is a defined amount you pay for covered health care expenses before your insurance starts to pay.
**Our medical deductible is $250/individual and $500/family

Adding a deductible is part of the long-term strategy of sustainablility for the Employee Health Plan. Just like the cost of everyday goods, healthcare costs are rising due to inflation. We want to make sure the health plan continues to provide high-quality coverage for years to come. By making this change now, we're taking proactive steps to protect the plan's financial future and maintain its value for you and your family.
The new medical deductible is much lower than other large employers have with their health benefits.
Even adding this new medical deductible, Cleveland Clinic is in the 90th percentile of plan "richness" when we compare ourselves to other large employers. 
We are still offering our members a market-leading health benefit. 

Yes, copays still apply even when the service applies to your yearly deductible.
The deductible is an annual fee that you pay before insurance begins to cover costs. A copay is a fixed fee paid at the time of your service. Deductibles reset annually, while copays apply even after the deductible is met. 

The deductible is $250 per person with a maximum amount of $500 for the entire family, regardless of how many members are covered under the plan. 
All deductible payments count toward the family deductible. Once the family deductible is met, all members receive post-deductible benefits, even if some haven't met their individual deductible.
If a family has only one person receiving services and they meet the individual deductible, the rest of that individual's services are paid at 100% with applicable copays even when the family deductible has not been met. 

Yes. Both plans have the same deductible. $250/individual and $500 max for families.

The deductible is not payable upfront as it is satisfied over time as the services are rendered and claims are processed. 

Yes. Since Cleveland Clinic utilizes Provider-Based billing and facility charges are billed separately from physician charges, these charges fall into the "outpatient setting" category where the deductible will apply.
For providers not located at Cleveland Clinic, it will depend on how the provider bills the service.
If they do not utilize Provider-Based billing, a $35 copay will apply to the professional claim.
If they do utilize Provider-Based billing, the deductible will apply to the facility claim.


Provider-Based Billing is a way that hospitals charge for services provided in practices, clinics or departments that are part of a hospital. These clinics can be billed as hospital outpatient even if they might be separate locations, but still fall under the hospital's ownership. The facility must be owned and operated by the main provider (hospital), typically located within 35 miles of the campus (if off-campus)
 

The deductible is what a specific member pays to the provider based on the service rendered. While you can always pay the statement balance for any of your dependents, only services for a specific dependent count towards their individual deductible.

Routine/screening services are not subject to the deductible.
Routine mammograms are considered screening services so no deductible will apply.
Diagnostic mammograms are subject to the deductible. If your screening mammogram comes back abnormal and further testing is required, the deductible will apply. ​

Services such as labs, x-rays, etc. done during an urgent care visit are billed separately and will apply to the deductible.
*See Quick Fact regarding Provider-Based Billing

*What is Provider-Based Billing?
Provider-Based Billing is a way that hospitals charge for services provided in practices, clinics or departments that are part of a hospital. These clinics can be billed as hospital outpatient even if they might be separate locations but still fall under the hospital's ownership. The facility must be owned and operated by the main provider (hospital), typically located within 35 miles of the campus (if off-campus)

Professional charges billed on a HCFA/CMS-1500 that are billed with an outpatient hospital place of service will apply to the deductible.  If the place of service billed is an office setting the deductible will not apply.

Because you’re seeing an in-network provider, the maximum you will owe is the allowed amount. It is the negotiated rate that EHP has agreed upon with the healthcare provider for covered services. The remaining balance is adjusted off and not your responsibility.
The allowed amount includes deductible, and any copay or coinsurance.


The allowed amount is the maximum amount the EHP will pay for a covered healthcare service. This is the negotiated rate that the EHP has agreed upon with in-network providers. The provider cannot bill the patient anything above the allowed amount.  

You and your dependents need to fill a 500oz bathtub with water (family deductible is $500)
You each have a 250oz bucket (individual deductible is $250)
You pour 250oz (you now have met your individual deductible and your allowed claims will now pay in full minus applicable copays/coinsurance), your spouse pours 150oz and your child pours 100oz
The bathtub is now full! (Family deductible of $500 is now met and everyone's claims will now pay in full, minus applicable copays/coinsurance)

*Copays/coinsurance will apply until the Out-of-Pocket Maximum has been met

Click here to view other scenarios of how the medical deductible will apply.

Beginning in 2026 the EHP and EHP Plus plans require a $35 copay for all specialty in-person and virtual visits. Last year, many specialty office visit services did not require a copay because the Aetna claim system only triggered a copayment when an evaluation and management (E&M) code was billed.
This inconsistency led to confusion among health plan members, as the same service would sometimes require a copay and sometimes it would not.
To address this issue, Aetna has updated their system coding to ensure a consistent copay of $35 for all specialty office and virtual visits. You may notice changes in the application of the specialty coding in the following services: Behavioral Health, Dermatology, Dietician, and Pain Management

It’s part of the long-term strategy of sustainability for the health plan. Just like the cost of everyday goods, healthcare costs are rising due to inflation. We want to make sure the plan continues to provide high-quality coverage for years to come. By making this change now, we’re taking proactive steps to protect the plan’s financial future and maintain its value for you and your family.
The increase to $20 is still lower than other large employers. CC is in the 90^th percentile of plan “richness” when we compare ourselves to other large employers. We are still offering our members a market-leading health benefit.

No. Habilitative Therapy services continue to not have copays. 

The reason we ask for physical therapy before an MRI is because it is best practice. Many patients who go through physical therapy can manage their pain and no longer need the MRI.

Florida Members only: Don't forget about Hinge Health! Members can sign-up with Hinge - the Physical Therapy app. (This has not yet been expanded to Ohio members)

When you have a surgical procedure done in an outpatient setting you now owe a $75 copay. This copay was applied to all other plans last year. We brought the Akron USW plan into alignment by adding it in 2026.

Maintenance medications must now be filled by the Cleveland Clinic Home Delivery pharmacy for the following states: OH, FL, PA, WV, VA, IN, IL, MI, WI, NV, NJ & NY
(Specialty meds only, can use CVS Home Delivery for all others in NY)

Prescriptions filled at CVS pharmacy now have a minimum of $10 and a maximum of $75. That is a change from previous years where the minimum was $5 and the maximum was $50.

Reminder that you are only able to utilize CVS for initial fills and cannot use them for maintenance medication refills.

For several years, we added providers in the following counties to our network due to an insufficient amount of providers in these areas:

• ​Indian River
• Martin
• Brevard
• St. Lucie

EHP – The EHP option includes the Cleveland Clinic, Quality Alliance (QA), and certain Florida-aligned providers. These networks include Cleveland Clinic facilities and employed physicians as well as contracted facilities in Ohio and Florida. If you elect this plan, you must use providers from this provider network.  

The EHP plan is supplemented with Aetna providers in the following specialties from the seven counties surrounding our Florida hospitals: Acupuncture, Allergy, Behavioral Health, Chiropractic, Dermatology, Endocrinology, Nutritionist,  Ophthalmology, Otolaryngology (ENT), Oral Surgery, Pain Management, Pediatrics and Podiatry. The seven counties include Brevard, Indian River, St. Lucie, Martin, Palm Beach, Broward and Miami-Dade.  

The use of Aetna providers for the specialty of OB/GYN in our Florida region will be limited to Aetna OB/GYN providers in the counties of Broward, Palm Beach and Miami-Dade. The non-Cleveland Clinic Aetna OBGYN providers that have been included in-network for EHP from Brevard, St. Lucie, Indian River and Martin counties will be removed from the EHP network. Our Cleveland Clinic providers and facilities, Martin Tradition and Indian River hospitals, are able to treat members for these services.  

EHP Plus – The EHP Plus option gives members access to the providers available in the EHP plan (above), PLUS Aetna’s Open Access Select network, which includes providers nationwide. 

EHP will continue to offer a comprehensive benefit plan with low out of pocket costs no matter which plan you elect, while premium and network size will differ. The choice is up to you, when you make your health plan elections during Open Enrollment.

If you are currently enrolled in the health plan and do not take action during open enrollment, your health plan coverage will default to the Employee Health Plan (EHP). More details on these health plans and the enrollment process will be made available as we get closer to open enrollment.   

Under the EHP Plus option, you receive access to two networks - the Cleveland Clinic, Quality Alliance (local) and the Aetna Select Open Access (national) network. This gives more flexibility to those who need to go outside of the Quality Alliance or those living outside of the northeast Ohio area. Because the EHP Plus option has access to nationwide providers, the cost will be higher.  This is the standard in any insurance offering. The benefit coverage is the same for both EHP and EHP Plus. Cleveland Clinic will continue to provide comprehensive medical and prescription drug coverage for our caregivers.  

Your Health Plan ID can be found on the front of your insurance ID card. For more information, click here. 
 

Yes. If an in-patient admission occurs following an out-of-network emergency room or urgent care visit, the EHP plan will cover the hospitalization. For all out-of-network admissions, we request that members call 1.888.246.6648, option 2. When possible, the member will be transported to a CC facility. If transport is not feasible, EHP covers the hospitalization at maximum coverage. 

No referral is required to visit a specialist under either the EHP or EHP Plus plans.

The Aetna provider search tool is the best way to verify the provider networks & includes provider directories for both plans, EHP & EHP Plus. 
You can access the search tools & job iad on the Find a Provider page. 
Having trouble finding your provider? Contact the Employee Health Plan for assistance at 216.986.1050, select option 1. 
if you are having trouble accessing the Aetna provider lookup site, you may contact the Aetna Concierge for assistance at 833.414.2331.

For coverage related questions, please refer to the My Plan and Benefits page or the Summary Plan Description.  If you have additional questions, you can Contact Us.  Please have the CPT Code (Current Procedural Terminology) and Diagnosis Code available when you call.  This code can be obtained through your provider’s office.

The Employee Health Plan will cover one routine exam per calendar year for adults. 
Pediatric members age 17 and under are covered for two routine vision exams per calendar year. Services must be provided by an in-network opthalmologist or optometrist.
Routine eye exams may also be called "well vision exams" & are comprehensive check-ups to assess vision and eye health. They are different from medical eye exams which are conducted when there are specific eye concerns. 

Both EHP and EHP Plus plans cover in-network behavioral health providers, including Cleveland Clinic employees and Aetna Open Access Network providers in Ohio and Florida. There is no out-of-network coverage except for emergencies or urgent care.

 

None of hte health plans require members to select a PCP. You can see a mid-level provider in either plan as long as they are in-network. 

PLEASE NOTE: Not all mid-level providers, like CNPs and PAs, are listed in the provider directory. This is because they sometimes bill under their associated physician’s office, and not as an individual provider.
 

Wooster Community Hospital is only available under the EHP Plus plan. Emergency and urgent care services are covered out-of-network under both plans after applicable copays.

With the geographic expansion and growth of Cleveland Clinic, it is necessary to change to a third party administrator who can provide a comprehensive provider network to accommodate the needs of our caregivers in these areas.  With the transition to Aetna, the EHP Plus plan will serve this purpose as we continue to grow. That is why Akron Children’s providers will be in the EHP Plus network. The benefit coverage is not changing, meaning still no deductible and lower copays.

Eligible dependents who are away at school, like college students, are covered no matter which plan option you have, including EHP or EHP Plus, as long as they use in-network providers for that plan.

The Employee Health Plan allows college students to visit their student health center for non-routine, non-preventive services. Additional services will be covered as a specialty visit with a $35 copay. Additional services may include, flu shots, tetanus shots, allergy therapy, and PT/OT/Speech Therapy, if these are provided. It is your responsibility to ensure the service you need can be performed at the college’s student health center for coverage.

There is no out-of-network coverage in either plan except for Emergency and Urgent Care visits. Urgent visits to the college student health centers for an acute illness are treated as such, but may initially be denied as not all college student health centers are contracted with Aetna. If you receive a bill, contact EHP Customer Service for resolution.
 

Foreign Country Claims:
Emergency services received while in a foreign country are covered, however, payment up front is typically required by the provider. To obtain reimbursement, the member must provide an itemized receipt from the provider which includes a description of services and codes (in English). A claim form then needs to be submitted to the Third Party Administrator along with the receipts.

Emergency Care:
Emergency and Urgent Care are covered at 100% regardless of the provider as long as the visit meets Emergency or Urgent Care criteria as defined in the Definitions of Terms in your Summary Plan Description.  A copayment is required for any emergency department visit. Observation stays in the hospital are not considered admissions and are subject to the ER copayment.
If the ER visit results in an admission, the ER co-payment will be waived and the admission copayment will apply. 

The Employee Health Plan requests members to contact EHP Medical Management at 216.986.1050 or toll free 888.246.6648, option 2 if the member requires admission (including unplanned admissions). This number is also on the back of your Health Plan ID card. 

Due to privacy laws we are not able to provide protected health information without a release form for anyone 18 or older.  See the Summary Plan Description or our privacy policy for more information.

The Cleveland Clinic offers several ways to pay your bill.  This link will walk you through paying your bill online through MyChart or MyAccount.   You can also Contact Us.

You may have received a bill because you owe a copay, coinsurance or deductible.  Specialist visits carry a copay with them for every appointment.  Also some scans and tests, such as an MRI, have a copay.  You may have also received a bill because the provider or service you received is not in the network, which has a copay and a deductible.  For more information please refer to your Summary Plan Description.  

If you have additional questions, please feel free to Contact Us.  Please be sure to have the bill available when you call. 

• Utilize primary care providers, either in-person or virtually, when possible. Cleveland Clinic also has multiple Express Care locations across the region that are available for acute illnesses or minor injuries. These services are covered at 100% with no out-of-pocket costs.
• Use Cleveland Clinic pharmacies. The pharmacy deductible is waived if using generic medications at Cleveland Clinic pharmacies.
• Tips to save on health costs in 2027:
  • Participate in Healthy Choice to earn premium discounts 
  • Enroll in a Flexible Spending Account (FSA). It is a tax-free option to put finds into an account to help pay for items such as prescriptions, copays and deductibles. The funds are available all at once and come out of your paycheck graduatlly throughout the benefit year
  • Trade in PTO to lower the cost of your benefits
• If you utilize Cleveland Clinic providers, you can set up balances on an interest-free payment plan to spread the cost over a longer preiod instead of paying it all at once. You can also pay one-time copays using payroll deduction.
• Speak to a Patient Financial Advocate prior to services, they can help you navigate additional options

Willis Towers Watson is a company that we contract with to conduct our dependent audit.  You must respond or your dependents will be terminated from our plan.  If you are enrolling dependents onto your plan you will need to provide dependent verification after you have elected coverage to ensure that the dependents you are adding are eligible for coverage. Eligible dependents include your lawfully married spouse and dependent children under the age of 26. After you have elected coverage in Workday, Willis Towers Watson, our Third Party Administrator (TPA) for dependent verification, will send a letter to your home address asking you to provide dependent verification documentation. See the Summary Plan Description (SPD) for more detailed information

When an employee becomes eligible for COBRA they have the opportunity to continue the coverage that they were covered under immediately prior to the COBRA qualifying event. This means that if they were enrolled in the EHP plan at the time they become eligible for COBRA, their only option to continue coverage is the EHP plan (not EHP Plus). However – they would have the opportunity to switch to EHP Plus during open enrollment (Inspira sends COBRA open enrollment notifications to COBRA participants in the fall).

Certain changes that affect you and/or your dependents – such as a marriage, birth, divorce, or qualifying for Medicare – and may result in the need to make changes to your benefit elections

If you experience a qualifying life event and wish to change your coverage, you must do so within 31 days of the event and provide the necessary supporting documentation. Any adjustment to coverage must be consistent with the change resulting from the qualifying life event. To initiate a life event change, visit the HR Workday and Portal. If you need additional assistance, please feel free to contact the HR Service Center at 216.448.2247, option 1.
 

Studies have shown that those who participate in Coordinated Care programs are healthier and manage their conditions more effectively.  Additionally, you may qualify for money saving discounts and reimbursements. The Coordinated Care Incentive FAQ page has a comprehensive list of the incentives and reimbursements that the Coordinated Care program offers.

To join Coordinated Care programs, please call the health plan’s Medical Management Department at 216.986.1050 or 1.888.246.6648, option 2.

• To join Coordinated Care programs, please call the health plan’s Medical Management Department at 216.986.1050 or 1.888.246.6648, option 2.
• For Rare or Complex Disease Management please visit our website.    
• For nicotine use visit our website for program options.

The health plan offers over 20 programs for these conditions including:
Coordinated Care Programs
·    Asthma (for adults and children) ·   
·    Congestive Heart Failure (CHF)
·    Depression (adults and children)
·    Diabetes *
·    Hyperlipidemia (high cholesterol)
·    Hypertension (high blood pressure)
·    Migraine (adults and children)
·    Nicotine Cessation (offered by EHP Wellness tobacco/nicotine )
·    Weight Management 

  * The Summary Plan Description contains information about the Diabetes program and copay reimbursement incentives for members under 18 years of age.


Rare or complex condition management programs (managed by AccordantCare):

• Amyotrophic lateral sclerosis (ALS) 
• Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) 
• Crohn’s disease ​
• Chronic Kidney Disease (CKD)
• Cystic Fibrosis 
• Dermatomyositis 
• Gaucher disease 
• Hemophilia 
• Hereditary angioedema 
• Lupus 
• Multiple Sclerosis 
• Myasthenia Gravis
• Myositis (includes Inclusion Body Myositis - IBM) 
• Parkinson’s disease 
• Polymyositis 
• Rheumatoid Arthritis (includes Juvenile Idiopathic Arthritis)
• Scleroderma 
• Seizure disorders 
• Sickle Cell Anemia 
• Ulcerative Colitis
• Pulmonary Arterial Hypertension (PAH)

Yes, you can ask to be assigned to a specific EHP Care Coordinator when you call to join. We will do our best accommodate your request, but we cannot promise that all requests can be met.

1. Members must utilize their EHP Medical and Pharmacy benefit for the supplies and medications in order for these items to be eligible for Coordinated Care program copay reimbursement.
2. The Employee Health Plan (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 some 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).
   • Hypertension program:  One (1) Upper ArmBlood Pressure Monitor (up to $55) OR One (1) Upper Arm Manual Blood pressure monitor with Stethoscope (up to $55 combined total) once every five (5) years.
   • One (1) Bathroom scale (up to $40.00) and One (1) Upper Arm Blood Pressure Monitor (up to $55) OR One (1) Upper Arm Manual Blood pressure monitor with Stethoscope (up to $55 combined total) once every five (5) years 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 occurs 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%.
6. Up to five (5) in network for EHP or EHP Plus plan members or Tier 1 Cleveland Clinic Martin Hospital Under 65 Retirees, Main Campus Residents and Fellows and Florida Residents and Fellows physician or physician assistant condition related office visit copayments per calendar year are reimbursable AFTER you have met all the program goals. The member becomes eligible from the date you meet all goals forward 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 from an in network for EHP or EHP Plus members or Tier 1 Cleveland Clinic Martin Hospital Under 65 Retirees, Main Campus Residents and Fellows and Florida Weston Residents and Fellows provider 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 an in network for EHP or EHP Plus members or Tier 1 Cleveland Clinic Martin Hospital Under 65 Retirees, Main Campus Residents and Fellows and Florida Weston Residents and Fellows 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 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 (2023).
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 Pharmacy deductible must be met each year prior to any reimbursement being released. Drug manufacturer coupons used to pay 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.

Documentation needs to be sent to Cleveland Clinic EHP Medical Management.  You must  include the member'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 / AC242
Beachwood, Ohio 44122

Acceptable forms of documentation required include:
1. Office copay receipts should include the Date of Service. The patient name on the receipts and the in network provider name for EHP or EHP Plus members 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 register receipts from the Cleveland Clinic/Akron General pharmacies or Cleveland Clinic Home Delivery. Both must be submitted in order to request reimbursement. We do not accept the pharmacy printouts. 

3. For DME qualifying medical supplies related to a program, purchased through an in network provider for EHP or EHP Plus members. 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.
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 cash register receipt.
c. We do not accept hand written receipts or pharmacy printouts.

We encourage you to keep a copy of all documentation submitted for your records.

You will find the information regarding what documentation is needed on the Coordinated Care Incentive FAQ page.

Reimbursement checks will be mailed to the policy holder’s address as listed in Workday from Aetna.  Please review any mailings received from Aetna.  Your reimbursement check will be on the bottom of a form that looks very similar to the Explanation of Benefits.

You will find information regarding your reimbursement check on the Coordinated Care Incentive FAQ page.

Qualifying receipts may take up to 90 days for processing. The claim must be submitted by your provider and paid by Aetna before any copay reimbursement can be processed. Please contact your EHP Care Coordinator if you have any questions. If your receipt does not qualify for reimbursement, you will be notified.

Yes, for more detailed information review the "When am I eligible for reimbursements and incentives? " area of the Coordinated Care Incentive FAQ page.

• Receipts must be submitted within six (6) months of the date of service. 
• You will find information on when you may submit receipts for reimbursement  on the Coordinated Care Incentive FAQ page.
• NOTE:  If you plan on retiring, you must submit all receipts before you retire.

Reimbursement check is made out to the policy holder of the health plan coverage.

EHP & EHP Plus 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.

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.

The EHP Medical Management department will process member requests to replace never received, lost or misplaced reimbursement checks totaling $20.00 or larger. For checks that are reissued, a replacement fee of $10.00 will be deducted for the original reimbursement.

 Checks totaling less than $20.00 will not be re-issued.

 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

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.

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.

Your annual pharmacy deductible is waived for generic prescriptions only if they are filled by Cleveland Clinic / Akron General Pharmacies and/or Cleveland Clinic Home Delivery. 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.
Please refer to your current Prescription Drug Benefit and Formulary Handbook for lists of brand name and generic medications.

Receipts must be submitted within 6 months of the prescription fill date.

NOTE:  If you plan on retiring, you must submit all receipts before you retire.

Only testing supplies (i.e. test strips and lancets) purchased from Cleveland Clinic pharmacies, Cleveland Clinic Home Delivery, or an in-network provider for EHP or EHP Plus members will be reimbursed. No receipts will be processed for any supplies filled by other pharmacies or providers. CVS Caremark mail order approved medications or testing supplies are NOT reimbursable unless the policy holder resides in a state that is not serviced by Cleveland Clinic Home Delivery Pharmacy. Receipts must be submitted within six (6) months of the date of purchase.   
 

• Insulin pumps and continuous glucose monitors require prior-authorization according to the EHP Summary Plan Description.
• These items must be obtained through an in-network provider for EHP or EHP Plus members.
• Copays for continuous glucose monitors, transmitter and/or receivers are reimbursable upon meeting all the goals of the Diabetes program.
• 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.
• The coinsurance is NOT reimbursable for glucometers.
• The member becomes eligible for copay reimbursement from the date they meet all the goals and going forward. You must continue to meet all the 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.

No, the Employee Health Plan and Healthy Choice cannot accept participation from another employer or insurance company. 

Both employees and their spouse if applicable, have an opportunity to earn a discount towards their health plan premium.

View the Program Overview Guide to learn more. 

Healthy Choice Program is only available to Employee Health Plan members and spouses if applicable. Dependent children, retirees, COBRA members and PRN employees are not eligible to participate. 
If you are a resident or fellow, contact an EHP Wellness Specialist at 216.986.1050, option 3.

The Healthy Choice Incentive Program runs from Jan. 1-Sept. 30 each year. You will have until Sept. 30 to complete the required 16 weeks of messages and submit your final metrics between Aug. 15-Sept. 30. 

Pregnancy changes your Program Requirements. If your Incentive Program is: 

• Care Coordinator Program: Contact your care coordinator or telephonic medical assistant to deetermine your new program requirements.
• Health Coaching Program: Contact your health coach to determine your new program requirements.
• Activity Program: Continue using your activity tracker for your participation credit. 

The Healthy Choice Program Requirements and FAQs can be found by clicking the link below or in your Healthy Choice portal.
Program Requirements and FAQs

A caregiver is eligible for the New Caregiver Program if they meet one of the following criteria: 

• Caregiver has not been employed at Cleveland Clinic within the 12 months prior to their most recent hire date

• Caregiver is newly enrolled in EHP benefits due to open enrollment or a life event change. If you're newly married, pleae contact an EHP Wellness Specialist at 216.986.1050, option 3.

A Track in the Health Coaching Program means you have a Track the Healthy Choice Program supports. You will message with a health coach in the Healthy Choice portal for support and to work toward goals to earn a premium discount. 

Frequent communication is key. Members who are most successful typically message their health coach at least 1-2 times per week. You will need to send a minimum of one message a week for 16 weeks to work toward full credit. Refer to your Program Requirements in your Healthy Choice portal for more information. 

New in 2026, you will be messaging with your health coach through the Healthy Choice portal. You can expect a welcome message upon enrollment in the program explaining the next steps. 

You can talk with your health coach if you have any questions or email us at EHPHealthCoaching@ccf.org

Additional details about the Health Caoching Program or FAQs can be found by clicking the link below or in your Healthy Choice portal. 
Program Requirements and FAQs

A Track in the Care Coordinator Program means you have one or more of the five Track(s) the Healthy Choice program supports. These Track(s) include: 

Asthma Track, Diabetes Track, Hypertension Track, Hyperlipidemia Track or Weight Track.  

You will work with a care coordinator or telephonic medical assistant for support and to work toward goals to earn a premium discount. 

If you get closed out of a Care Coordinator Program from not responding to your care coordinator, you will need to re-enroll through the Healthy Choice portal. 

The name and contact information for your care coordinator or telephonic medical assistant can be found in your Healthy Choice portal. 

Additional details about the Care Coordinator Program or FAQs can be found by clicking the link below or in your Healthy Choice portal.  
Program Requirements and FAQs

Premium appeals can be requested between Oct. 4, 2025, through March 31, 2026. 

A BFA can be submitted by March 31 for an appeal from the Weight Track. The appeal letter will notify you if you have been removed from the Weight Track. 

Appeals after March 31 will not be accepted. 

If your Incentive Program was Unknown Status at the beginning of the year, you are required to submit an updated Health Visit Form.  This will update your Incentive Program, and you will have 30 days from the date your Health Visit Form was received by the Employee Health Plan to submit a BFA and request an appeal.  The appeal letter will notify you if you have been removed from the Weight Track.  

Members are only provided a one-time exception during the life of the Healthy Choice Program.
The member must request this appeal through their care coordinator or by calling a wellness specialist. 

If you were married between Jan. 1 and June 30 your spouse must participate in their required Track(s), and their participation will count towards your premium discount. If you were married July 1 or after, your spouse's participation will not count towards the premium discount, however they will need to enroll and start participating for the following year. 

No. Since the New Caregiver Program is an introductory program, either the spouse or the caregiver can participate to earn the discount the following year. 
In year two, both the spouse and the caregiver will need to participate to maximize their discount. 

No. We do not accept screenshots of steps or active minutes to count towards participation. It is the member's responsibility to log into their Healthy Choice portal weekly to ensure their device is syncing and showing in their portal. 

If you have documentation of a divorce during the current year, then your spouse's participation will not count toward your premium discount. 

Once an appeal is entered and submitted, the Healthy Choice Review Panel will have a response within 30 days. The member will receive a letter with the appeal findings via the United States Postal Service.  

A member can request a one-time exception up to 30 days after the program deadline to request late submission of final metrics to be considered. The Healthy Choice Review Panel will determine if a one-time exception has been used in the past.  

A Track, with approved documentation, will be considered by the Healthy Choice Review Panel, Care Coordinator or Medical Director for removal. If approved, the Track would be removed for a two-year timeframe. A member will need to submit a new appeal after the two-year timeframe. 

No. While the deadline to submit a Health Visit Form is Sept. 30, it is highly encouraged to have the Health Visit Form submitted before March 31. This allows members to enroll and work toward a full credit premium discount by March 31 or by June 30 to work toward a partial premium discount. Members can also call and speak with a Wellness Specialist to enroll in the Care Coordinator Program or Health Coaching Program if they believe they have one of the five Healthy Choice Program Track(s). 

No. Your spouse would need to talk with their care coordinator or a Wellness Specialist to request an appeal.

All active Cleveland Clinic Employee Health Plan members with any of the 19 conditions are eligible to participate free of charge.
(Retirees are not eligible to participate in the program)

Participation is voluntary and members can opt out at any time.  A variety of service options are available to meet the unique needs of all its members.  Members continue in the program if they are eligible and can participate in a variety of ways.

Members are selected based on claims and referrals from individual case management. Once identified, eligible members will receive introductory mailings and phone calls to enroll in the program.

During the first quarter of the new year EHP and AccordantCare will be analyzing the previous year's data to determine eligibility for an incentive.  Once the analysis is complete, AccordantCare will be advised of those participants receiving an incentive. 

AccordantCare doesn’t replace the care members are already receiving from their doctor and other providers. It adds extra support to their care. The AccordantCare nurse works closely with the health care team to help members stay on track.

• 24/7 access to a dedicated program nurse who specializes in supporting the management of a member’s complex condition and provides ongoing support and education.
• Routine health risk assessments conducted by a program nurse to identify risk factors, gaps in care and opportunities for optimal self-management
• Personalized education and monitoring based on individual needs, including specialized support for health goals
• Monthly newsletters focusing on condition-specific self-management strategies
• Targeted educational mailings triggered by gaps in care and adverse events
• A wide range of online resources, including educational materials and interactive forums, available at Accordant.com
• Physician notification of program enrollment and ongoing collaboration on the member’s plan of care
• Help finding support resources and caregiver assistance
• Case management and coordination of care
• Periodic wellness outreach, including flu and pneumonia vaccine reminders

Incentives will be disbursed during the first quarter of a new year and mailed to homes.

If you feel you met all of the incentive requirements and did not receive a check, you may email EHP at EHPAccordantAppeals@ccf.org to open an appeal.  Your information will again be reviewed by both EHP and AccordantCare.  An answer will be provided to you within 14 days.  Please provide the following information when emailing EHP:

• Full Name
• EHP health plan ID found on the front of your medical ID card
• Date of birth
• AccordantCare Member ID if available

If your primary health insurance is not Employee Health Plan, you do not qualify for an incentive.

If you feel you met all of the incentive requirements and did not receive a check, you may email EHP at EHPAccordantAppeals@ccf.org to open an appeal.  Your information will again be reviewed by both EHP and AccordantCare.  An answer will be provided to you within 14 days.  Please provide the following information when emailing EHP:

• Full Name
• EHP health plan ID found on the front of your medical ID card
• Date of birth
• AccordantCare Member ID if available

Yes, every member of a family has their own health plan ID number and their own health plan ID card.  

Once you have your health plan ID card with your EHP ID number you can join a Healthy Choice or Coordinated Care program.

The two most common reasons that a new member is told they do not have coverage are:

The prescription drug benefit is included in your Employee Health Plan coverage, so when you enroll in the Employee Health Plan you are automatically covered. CVS Caremark administers this plan and will mail you a CVS Caremark prescription ID card about 4 weeks after you have elected coverage under the Employee Health Plan in Workday. If you need to have a prescription filled prior to your CVS Caremark ID card arriving you will need to pay for the prescription out of pocket, then you can apply for a reimbursement after your card has arrived. 

Is the prescription for a medication you take every day?  Maintenance medications are those that are filled on a regular basis. These must be refilled through Cleveland Clinic Community pharmacies or through Cleveland Clinic Home Delivery pharmacy. You may set up an account through MyChart. 

No, a referral is not needed to see a specialist.

Please visit our Find a Provider page on our website under your applicable plan.  

The Health Plan does not have out-of-network coverage except in case of emergency.  If you see a provider or go to a hospital that is not in-network, except in the case of an emergency, you will be responsible for all charges and fees.
 

Tier levels only apply to Martin Health Retirees Under 65. The Tier refers to the network that your provider or facility is in, under the service network.  The plan will always pay the most for services provided within the tier I network.  If you choose a doctor or hospital in tier 2 there will be a coinsurance and a deductible that may apply. See the Summary Plan Description for more information.
 

Once you have submitted your health plan coverage elections, it takes up to 4-6 weeks to receive your ID cards in the mail. To access your cards before they arrive, view the instructions on this page. 

Your coverage effective date will be retroactive to your date of hire, or the date of a qualified life event – however, it takes about 4 weeks for your health plan ID cards to arrive in the mail after you have elected coverage in Workday.

If you have questions regarding your eligibility effective date, please Contact Us.

All caregivers start at the bronze “standard” premium level. You can only earn a different premium by participating in our Healthy Choice program.

Electing your benefits is a two-step process:

1. Learn About Your Benefits: Access the HR Portal from the Announcement section of the Workday homepage to review Cleveland Clinic's benefit plans & available options. 
2. Elect Your Benefits: Once you've made your selections, open the benefits task in your Workday inbox (located in the upper right corner of hte homepage next to your photo) & follow the on-screen instructions to complete your elections. 

If your provider(s) is a Cleveland Clinic or Cleveland Clinic Quality Alliance provider, they will continue to be in both EHP and EHP Plus plans. Please reference the Aetna provider search tools to identify physicians and facilities covered in each of the plans.

EHP provider search
EHP Plus provider search
Martin Health Retirees Under 65 provider search

Having trouble finding your provider? Contact the Employee Health Plan for assistance at 216.986.1050, select option 1. 

EHP – The EHP option includes the Cleveland Clinic, Quality Alliance (QA), and certain Florida-aligned providers. These networks include Cleveland Clinic facilities and employed physicians as well as contracted facilities in Ohio and Florida. If you elect this plan, you must use providers from this provider network.  

The EHP plan is supplemented with Aetna providers in the following specialties from the seven counties surrounding our Florida hospitals: Acupuncture, Allergy, Behavioral Health, Chiropractic, Dermatology, Endocrinology, Nutritionist,  Ophthalmology, Otolaryngology (ENT), Oral Surgery, Pain Management, Pediatrics and Podiatry. The seven counties include Brevard, Indian River, St. Lucie, Martin, Palm Beach, Broward and Miami-Dade.  

The use of Aetna providers for the specialty of OB/GYN in our Florida region will be limited to Aetna OB/GYN providers in the counties of Broward, Palm Beach and Miami-Dade. The non-Cleveland Clinic Aetna OBGYN providers that have been included in-network for EHP from Brevard, St. Lucie, Indian River and Martin counties will be removed from the EHP network. Our Cleveland Clinic providers and facilities, Martin Tradition and Indian River hospitals, are able to treat members for these services.  

EHP Plus – The EHP Plus option gives members access to the providers available in the EHP plan (above), PLUS Aetna’s Open Access Select network, which includes providers nationwide. 

No, these must be purchased through an in-network provider with a prescription.  Compression stockings are covered at 80% and are limited to six pairs per year.
Medicare eligible members -- Medicare covers compression stockings for diagnoses of Lymphedema or Venous Stasis Ulcer. If you are a Medicare eligible member & do not have either diagnosis, you may pay out-of-pocket & then mail the invoice & proof of payment directly to EHP:
Cleveland Clinic Employee Health Plan
Attn: EHP Invoicing
25900 Science Park Dr./Mail Code: AC242
Beachwood, Ohio 44122

Hearing aids are covered at 50% of the billed amount up to $3,500 per ear; one aid per ear every three years. Evaluation, consulting, and dispensing fees are covered at 100%. Repair of hearing aids ARE NOT covered. There is NO coverage of the hearing aids, evaluation, consultation, or dispensing fees obtained outside of the network. This information is also available in the Summary Plan Description.

Custom-made orthotics are covered at 80% of the allowed amount after your $50 copayment. If the contracted rate is less than the amount of the copayment, the member is still responsible for the corresponding copayment/coinsurance. 

General orthotics are not a covered benefit.  

Orthopedic shoes and diabetic shoes are not considered orthotics.  

This information is also available in the Summary Plan Description.

You can go to Find a Provider and search by your specific plan.  You may also Contact Us.

The Health Plan benefit for durable medical equipment (DME) is 80/20.  Which means we pay 80% of the cost and you pay 20% & is subject to the medical deductible as long as you use an in-network provider. Some equipment does require prior authorization. For exceptions and more information please review the Summary Plan Description.

As part of the Employee Health Plan (EHP) and EHP Plus plans with Aetna, breast pumps are covered at 100% if obtained through an In-Network Durable Medical Equipment provider or a Cleveland Clinic Pharmacy.
The EHP plans cover: 
• One electronic breast pump in a 12-month period
• One manual pump in a 12-month period
The pump must be purchased before the child reaches 36 months of age for a new pregnancy. New tubing and accessories are covered annually.
For the claim to be covered, it must be associated with a pregnancy-related claim and diagnosis code. Coverage will be 80% for certain upgraded pumps and packages. Pricing is available through each individual vendor. Questions related to the pumps and products should be directed to the vendor.
EHP and EHP Plus members may search the provider directory on their Aetna Health accounts to find in-network Durable Medical Equipment providers who offer breast pumps and supplies. For your convenience, a list of in-network providers is available below; however members must always check the plan directory for the most up-to-date information (EHP Provider Search  |  EHP Plus Provider Search). Members may also call the Employee Health Plan or the Aetna Concierge lines to verify provider network status. EHP, Aetna and other contact information is located on our web site at clevelandclinic.org/healthplan.
Each supplier’s process for purchase can differ. Make sure to follow the prompts on the web site for the vendor you choose.
The following Durable Medical Equipment suppliers offering breast pumps and supplies are in-network as of December 1, 2024:
• Cleveland Clinic Pharmacies
• Acceleron
• Edgepark
• Mommy Xpress / Pediatric Products LLC
• Pumping Essentials
• Yummy Mummy

You can purchase a breast pump at Cleveland Clinic pharmacies with a prescription, but you can also use another in-network durable medical equipment (DME) provider.  
See Section Three under "Coverage Clarifications" in the Summary Plan Description for more information.

A CPAP/BIPAP machine can be obtained by going through a durable medical equipment (DME) provider.  You can go to Find a Provider and search by your specific plan.  You may also Contact Us.

Coverage is effective from your first day of active employment. You must enroll within 31 days of your start date.  The sooner you enroll, the sooner you will receive your ID cards.  It can take 4-6 weeks for your coverage to become activated in our prescription claims system; therefore, we recommend filling your medication(s) one final time under your previous pharmacy benefit coverage prior to termination.  This will allow you additional time during the transition to your new coverage.

During the transition, should you need to fill a prescription, CVS will reimburse for covered, formulary medications filled at in-network pharmacies and paid for out-of-pocket.  Reimbursement is based on the policies and coverage restrictions within our benefit design.  If there is an urgent medication need before your coverage is activated, contact EHP Pharmacy Management at 216.986.1050, option 4 for verification of coverage policies for the medication(s) needed.

Once your pharmacy coverage is activated, make sure you are filling your prescriptions on a timely basis.  Our network includes Cleveland Clinic Outpatient Pharmacies and CVS Pharmacies.

You can ask your provider to prescribe a 90-day supply of your non-specialty medications, which can be filled at any Cleveland Clinic Outpatient Pharmacy. Specialty medications are limited to a 30-day supply only. 

We encourage the use of the Cleveland Clinic Outpatient Pharmacies and Home Delivery Pharmacy for your acute and maintenance medication needs.  These pharmacies offer the lowest out-of-pocket expenses, and the deductible can be waived for prescriptions filled with a generic medication.  You can fill your initial prescriptions at any in-network pharmacy.  However, refills for maintenance medications must be filled either at Cleveland Clinic Pharmacies or CVS Mail Service.

Cleveland Clinic Pharmacies are not licensed in all 50 states.  If you live in a state that cannot be serviced by Cleveland Clinic Outpatient Pharmacies or Home Delivery, you can utilize CVS Mail Service for refills of maintenance medications.

Additional information about the pharmacy network and mail order options can be found in your Summary Plan Description. 

The Prescription Drug Formulary Handbook can be found on our website at employeehealthplan.clevelandclinic.org.  Select your applicable plan under “My Plan and Benefits”.

If you have any questions, please contact EHP Pharmacy Management at 216-986-1050 opt 4 or email us at ehprxmgmt@ccf.org. Please allow 24 hours for a response to any messages.

At this time, the EHP does not cover anti-obesity medications. We continue to review on a regular basis the outcomes and cost data from peer-reviewed medical literature to support our decision-making around coverage of these medications, while maintaining affordable health care premiums for our members and the health plan. Any weight loss medications that are purchased, members pay 100% co-insurance on the discounted price of the medication. The member’s out of pocket expense does not apply toward their annual pharmacy deductible nor their annual out-of-pocket maximum, they cannot be reimbursed for their medication or office visit expenses. 

We encourage participation in the EHP’s Healthy Choice weight management program and other non-pharmaceutical weight management offerings. 

For additional questions, contact EHP Pharmacy Management at 216.986.1050, option 4.   

Yes, the Prescription Drug Benefit includes an annual deductible of $200 for individuals and $400 for families.  This applies to brand-name medications filled at Cleveland Clinic Pharmacies, as well as both brand-name and generic medications filled at non-Cleveland Clinic pharmacies. 

Yes, we allow overrides in some cases. If you have lost a medication, you will be charged 100% of our cost for the replacement supply. If your medication was stolen, we require a police report to be submitted to the EHP Pharmacy Management Department before a replacement supply will be authorized.

No. The pharmacy network is the same for both EHP and EHP Plus. 

You can view your CVS Rx card on the CVS/caremark website.  Once on the site and logged in, click on Plan & Benefits on the navigation bar and then Print Member ID Card.  Within this area, you can also request a new card.

If you have not received your prescription drug card within 60 days, you can visit caremark.com, create an account and print an electronic version of your card. 
If you prefer a hard copy of the card, please contact the EHP Pharmacy Management Department at 216-986-1050, option 4. They can order you a card and it takes 10-14 business days to receive in the mail. 

You can view your CVS Rx card on the CVS/caremark website.  Once on the site and logged in, click on Plan & Benefits on the navigation bar and then Print Member ID Card.  An image of your card will then be displayed. 

You can view your CVS Rx card on the CVS/caremark website.  Once on the site and logged in, click on Plan & Benefits on the navigation bar and then Print Member ID Card.  Within this area, you can also request a  new card.

A member offering is a reduced cost or free program offered to members, spouses or dependents on the Employee Health Plan. Below are some of the member offerings. Contact each program facilitator for details.  

• Healthy Choice 
• Fitness Center Memberships 
• Weight Loss Programs 
• Nutrition Visits 
• Nicotine Cessation

No.  Some of the programs, for example Weight Watchers, require the member to pay part of the program cost.

Some of our programs do require participation. Find more information on the EHP website under Member Offerings or contact the specific program facilitator. 

No, the Employee Health Plan does not reimburse for programs that are not part of member offerings. 

No, the Employee Health Plan is not able to offer Silver Sneakers, Prime or Renew Active or any other programs to retirees. 

To unenroll from a program, contact the program facilitator for more details. 

Members, spouses and dependent children on the Employee Health Plan, who are not on the retiree plan or PRN, are eligible for programs offered. Some offerings may have restrictions for minors that are not imposed by EHP. Contact each program facilitator for details. 

In conformity with current IRS rules and regulations, the value of member offerings or wellness programs is generally considered taxable income and reportable on your Form W-2.

Yes, precertification is required through the EHP Medical Management Department. The members must call the Medical Management Department when the surgery workup starts, to initiate the precertification process. To be eligible for surgery, the member must meet the HBP’s established clinical criteria (see below). Please note, a member may qualify for surgery through the Cleveland Clinic Bariatric and Metabolic Institute or other approved provider, BUT NOT meet HBP clinical criteria. In this instance, the surgery will not be authorized for coverage and the member is not eligible for any reimbursements.

• Member must have a BMI greater than 40 (or exceeding 37.5 if of Asian ancestry) OR

• Members with a BMI of 35 to 39.9 (or exceeding 32.5 to 37.4 if of Asian ancestry) who have a significant co-morbidity(ies) such as hypertension, diabetes, coronary artery disease, sleep apnea or nonalcoholic steatohepatitis(NASH)/metabolic dysfunction-associated steatotic liver disease (MASH) which are not controlled by maximum conservative treatment.

• Members must be enrolled and participating in the Care Coordinator program Weight Track and any other identified track(s) such as diabetes or hypertension for at least one-month before their surgery date.

• If a member with a BMI between 35 to 39.9 does not meet the above criteria and gains weight to reach a BMI of 40, they will not be considered for surgery for one year.

• Laparoscopic band placement (lap band surgery) is not a covered benefit.

An upfront $2,750 copayment is required and collected by the surgeon or facility, for the surgical procedure to be scheduled. If you are an employee, ask your CCF provider if you are eligible for a payroll deduction.

The surgical copayment is eligible for reimbursement through the EHP Coordinated Care department, based on a 5 ½ -year post-surgical schedule monitored by our Care Coordinator team. Earned reimbursements of the surgery copayment are made only to actively employed HBP members or their eligible dependents who successfully participate in the required Care Coordinator Program Track(s).

Not all bariatric surgery procedures are a covered benefit. You or your provider should submit a precertification request to determine if your surgery is eligible for coverage. Surgeries considered experimental or investigational are not covered.

The removal of excess skin after bariatric surgery i.e. panniculectomy (apron like layer of skin and fat that hangs over the lower abdomen), abdominoplasty (tummy tuck), brachioplasty (arm lift), or liposuction is considered cosmetic in almost all instances and not a covered benefit. Precertification is required to determine eligibility.

Bariatric Surgery Copay Reimbursement is based on the member attending all follow-up visits within specified time frames and obtaining any follow up care/services ordered by their provider including lab work.
The following visits have reimbursable copays under the program:
PROCEDURE – facility, surgeon, anesthesia copay $2750 covers the global post operative 90-day period
POST-OPERATIVE CARE: Surgeon or any provider visits post operative 90-day period (copays at 6 months, 1 year, 2 ½ years, 3 ½ years, 4 ½ years, 5 ½ years)

•  The $2,750 copayment must be paid in full before the member is eligible to start receiving reimbursements they earned.
• The member must remain an actively employed or COBRA member of EHP to receive ANY reimbursement. See the current SPD for eligibility information.
• Members covered by other primary insurance are not eligible for further reimbursement. EHP must be primary coverage to be eligible for reimbursement.
• Members will never be reimbursed more than they have paid in copays. Please refer to your EOB (Explanation of Benefits) for determination of applicable copay amount. If your copayment on the EOB is less than what you paid at the time of service, you will be required to go back to the department for the difference. Reimbursement will only be processed for the applied copay amount from the EOB.

Members on the EHP plan must have surgery at a Cleveland Clinic Bariatric and Metabolic Institute facility.

EHP Plus members who live within a 130-mile radius of Cleveland Clinic must have the services completed at a Cleveland Clinic Bariatric and Metabolic Institute facility. If living outside of the 130-mile radius, services must be completed by an Aetna Institute of Quality Bariatric Surgery facility.

To be eligible for this benefit, a member must be a participant in the Health Benefit Plan (HBP) for a minimum of two consecutive years (24 months). If you are a new member from a recently acquired CCHS entity, 24 months participation in your previous health plan is required. The employee member or their eligible dependent must also be at least 18 years old.

As soon as a member decides with their physician/healthcare provider that a bariatric surgery procedure is being recommended, the member MUST call Medical Management. 1-888-246-6648 or 216-986-1050 option 2 to talk over bariatric surgery coverage requirements.

The member is required to participate in the precertification process for these services to ensure their understanding of potential treatment options, to ensure the member has participated in maintenance therapy before advancing to a more aggressive therapy, and to ensure the correct treatment in the correct setting. If the member does not participate in the precertification process before obtaining the surgery, there will be NO COVERAGE/REIMBURSEMENT for the service.

There is no impact to your retiree medical benefit if you choose to elect that coverage as part of your retirement process. The same two EHP and EHP Plus options will be offered to you. If you plan on retiring, report your retirement date to ONE HR to start the retirement process.

Please call the HR Service Center at 216.448.2247 or (877) 688.2247 and select the option for Human Resources.