Coordinated Care Incentive FAQs

Coordinated Care Incentive FAQs

Effective January 1, 2024

A printable version of this page is available for your convenience by clicking here

Reimbursements and Incentives

To be eligible for the Reimbursements and Incentives listed below, you must use an in-network provider. The exception is DME for Asthma, CHF, and HTN which may be purchased from any provider.

• EHP Plan network is QA/Cleveland Clinic
• EHP Plus network is QA/Cleveland Clinic and Aetna Select Open Access
• Cleveland Clinic Martin Hospital Retirees under 65, Main Campus Residents and Fellows and Weston Residents and Fellows Plan is Tier 1 Network QA/ Cleveland Clinic

Caregivers and families residing in states not eligible to participate in Coordinated Care (CC) are directed to participate in either the eCoaching program or use of an activity device. Contact Us if you have questions.

Due to RN licensure criteria, your ability to participate in a Healthy Choice coordinated care program depends on your state of residence. If you are able to participate in a coordinated care program, you may also be eligible for co-pay reimbursements. Please see the table below to determine your eligibility to participate in the coordinated care program, as well as the in-network pharmacy or mail-order pharmacy for your state to ensure you receive co-pay reimbursements. Please note that prescription medications/testing supplies obtained at CVS store pharmacies are NOT eligible for reimbursement, even if it is for the first fill or immediate need of a medication.

Healthy Choice Eligibility for Participation by State and In-Network Pharmacy for Copay Reimbursement

*NV members can get maintenance Rx at CVS store pharmacies, but CVS store and CVS Mail Order/CVS Specialty fills are not eligible for a co-pay reimbursement.

To qualify for co-pay/co-insurance reimbursement:

1.  Members must meet eligibility requirements.

2.  Members residing in one of these states:  Florida, Indiana, Michigan, Nevada, New Jersey, Ohio, Pennsylvania, Virginia, or Wisconsin:

• Must obtain prescription maintenance medications/testing supplies through:
  • Cleveland Clinic Outpatient Pharmacies or Cleveland Clinic Home Delivery Pharmacy/Cleveland Clinic Specialty Pharmacy

3.  Members residing in all other states not listed in #2 above

• Must obtain prescription maintenance medications/testing supplies through:
  • CVS/Caremark Mail Order Pharmacies or CVS/specialty Pharmacies

4.  Receipts must be submitted within six (6) months of the fill date/date of service/date of purchase.

• Please submit both Tax receipt and detailed register receipt
• If you plan on retiring, you must submit all receipts BEFORE the date of retirement. (Except Martin Health Retirees under 65)

5.  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.
• For any BRAND name medications eligible for co-pay/co-insurance reimbursement: the annual pharmacy deductible must be met first.

Please note: Prescription medications/testing supplies obtained at CVS Store Pharmacies are not eligible for the Coordinated Care Reimbursement Program.

What do I need to do to become eligible for reimbursements and incentives?

1.  Members must utilize their EHP Medical and Pharmacy benefit for the services, supplies and medications for these items to be eligible for Coordinated Care program co-pay reimbursement.

2.  to receive any co-pay/co-insurance reimbursement:

• Member's primary insurance must be one of the Employee Health Plans
• At the time receipts are submitted for payment

1. EHP card holder (insured) must be actively employed at CCHS, or be active on the policy, or be on COBRA.
2. Insured's spouse and all eligible dependents on the plan must be active on the policy.

3.  Once you enroll in a specific program, the co-pays for the following screening supplies required for you to manage the chronic condition can be reimbursed.

In order to be eligible for the Reimbursements and Incentives listed below through the EHP Pharmacy Benefit, members must use the following in-network pharmacies based on the state where they reside:

• Florida, Indiana, Michigan, Nevada, New Jersey, Ohio, Pennsylvania, Virginia, West Virginia, or Wisconsin

• Cleveland Clinic Outpatient Pharmacies OR
• Cleveland Clinic Delivery Pharmacy/Cleveland Clinic Specialty Pharmacy

• Florida, Indiana, Michigan, Nevada, New Jersey, Ohio, Pennsylvania, Virginia, West Virginia, or Wisconsin

• Cleveland Clinic Outpatient Pharmacies OR
•  Cleveland Clinic Delivery Pharmacy/Cleveland Clinic Specialty Pharmacy

Durable Medical Equipment (DME) Eligible for Reimbursement

Please note:  not eligible if other insurance is Primary.

Office Visits Eligible for Reimbursement

Not eligible if other insurance is Primary.

In order to be eligible for the Reimbursements and Incentives listed below, the member must see an in-network provider.

• EHP Plan network is QA/Cleveland Clinic
• EHP Plus network is QA/Cleveland Clinic and Aetna Select Open Access
• CC Martin Health Retirees under 65, Main Campus Residents and Fellows and Weston Residents and Fellows Plan is Tier 1 Network QA/ Cleveland Clinic

When is Member Eligible for Reimbursement? After the member reaches compliance in the program and as long as the member continues to maintain that compliance. (Eligible from compliance date forward).

The office visit must be related to the same condition as the program the member is enrolled in and are limited to a total* of five (5) visits per year for all programs (not per Specialty), except Diabetes and Depression (*see program details below).

Medications Eligible for Reimbursement*

Not eligible if other insurance is Primary.

*See EHP Coordinated Care (CC) Medication Reimbursement Lists of eligible medications for each different program.

Diabetes and Asthma

• Glucagon therapy and generic epinephrine pens are eligible for copay reimbursement upon enrollment for members in the Diabetes and Asthma programs respectively.

     The annual pharmacy deductible must be met first for any BRAND name medications that are eligible for copay reimbursement.

     These are the only medications eligible for copay reimbursement upon enrollment.

• Eligible for reimbursement 6 months (uninterrupted) from compliance date forward (the date all program goals are met) and remains in compliance. This also applies to needles, pen tips and syringes for members in the Diabetes program.

Generic Medications

• If a generic medication is available, only the generic medication will be eligible for copay/coinsurance reimbursement, unless the member has a prior authorization from the EHP Pharmacy Management department on file.

Prior Authorization

• Medications which require a prior authorization must have an approval on file to be reimbursed.

Pharmacies Used

• All prescriptions MUST be filled at the following in network pharmacies based on the state where the member resides:

   -  Florida, Indiana, Michigan, Nevada, New Jersey, Ohio, Pennsylvania, Virginia, West Virginia, or Wisconsin

      -  Cleveland Clinic Outpatient Pharmacies OR

      -  Cleveland Clinic Home Delivery Pharmacy/Cleveland Clinic Specialty Pharmacy

   -  All other states

      -  CVS/Caremark Mail Order Pharmacies OR

      -  CVS/specialty Pharmacies

• Prescriptions filled at CVS store pharmacies are NOT eligible for reimbursement.
• Members must use the EHP Pharmacy benefit to be eligible for reimbursement. If the member paid cash or used a discount card without using the EHP Pharmacy benefit, they will not be reimbursed.

Pharmacy Deductible

• The Annual pharmacy deductible MUST be met prior to any reimbursement being released for BRAND name medications.
• The deductible is waived for generics ONLY if they are filled at one of the Cleveland Clinic pharmacies.
• The deductible is NOT waived for generics filled at CVS/Caremark Mail Order and CVS/specialty Pharmacies. Members residing in states that must use CVS/Caremark Mail Order and CVS/Specialty pharmacies for reimbursement MUST meet their deductible prior to any reimbursement being released.
• Annual Pharmacy deductible: $200 Individual, $400 Family.

Coupons

• Drug manufacturer coupons used to pay a deductible will NOT be eligible for this reimbursement program.

• If one is used, the first $200.00 of the medication actually paid by the member is considered non-reimbursable.

Over the Counter Medications

• Over the counter medications are NOT reimbursable.

Receipts

• To request reimbursement, members must provide:

• Original tax receipt/bar code receipts AND the detailed cash register receipt from the Cleveland Clinic Outpatient Pharmacies (both must be submitted)
• Shipment receipts AND the detailed cash register receipt from Cleveland Clinic Home Delivery/Cleveland Clinic Specialty Pharmacies (both must be submitted)
• Shipment receipts from CVS/Caremark Mail Order or CVS/Specialty pharmacies

Receipts must be submitted within 6 months of the fill date to request reimbursement.    

PrudentRX

If a member is on specialty medications that qualify for the PrudentRx specialty medication co-pay program they 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. 

• These costs are not eligible for Coordinated Care medication reimbursement.

What documents do I need to send in for reimbursements?

Acceptable forms of documentation required include:

Office Visit Receipts

• Office co-pay receipts should include the Date of Service.

• The patient (member) name on the receipts and the provider’s name are preferred but not required. 
• If the member paid the co-pay after the visit, the Date of Service must be included on the documentation submitted.

• 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.

Durable Medical Equipment (DME) Receipts

For DME qualifying medical supplies related to a program, purchased through an in-network provider, and verified through Aetna’s website: 

• Submit the shipping ticket, invoice, or itemized statement from the DME provider that shows the patient’s name, date of service, and amount paid along with 
• Proof of payment: Canceled check or payment receipt for a credit card statement

Please note both must be submitted to request reimbursement.

WE CANNOT ACCEPT THE FOLLOWING AS PROOF OF PAYMENT: 

• Handwritten receipts for office visits
• Pharmacy print outs 
• Explanation of benefits received from Aetna or UMR (Florida Weston members). 
• 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.

Additional resources as well as examples of receipts to submit for reimbursement can be found on the Coordinated Care FAQ from the Resources tab on the Employee Health Plan website. 

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

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: 

• Patient’s name AND
• One (1) other individual identifier such as: date of birth, and/or the Member ID number

You have three (3) submission options: 

1. Scan and Email: [email protected] 
2. Fax to 216.442.5795 to the Attention of Reimbursements 
3. 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 for Office visits and durable medical equipment (DME) may take up to 60 days for processing. 

• The claim must be submitted by your provider and paid by Aetna or UMR before any co-pay reimbursement can be processed. 

If your receipt does not qualify for reimbursement, you will be notified. 

Please contact your Care Coordinator if you have any questions. 

How do I get my reimbursement check?

Release of reimbursement funds is dependent on confirmation that a claim has been paid by the Third-Party Administrator, Aetna or UMR (for Weston, Florida members)

Reimbursement checks will be mailed from Aetna or UMR to the policy holder’s address as listed in Workday.

• Please review carefully any mailings received from Aetna or UMR.

• Your reimbursement check will be on the bottom of a form that looks very similar to the Explanation of Benefits.

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?

Aetna will process member requests to replace never received, lost, or misplaced reimbursement checks. 

• Must be over 30 days since a check was issued.
• Member will need to contact Aetna directly by phone at 833.414.2331

Cleveland Clinic Weston, Florida plan members (2023 dates of service): 

UMR will process member requests to replace never received, lost, or misplaced reimbursement checks. 

• Must be over 30 days since a check was issued. 
• Will only replace checks totaling $20.00 or larger. 
• Member will need to contact their Care Coordinator
• 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, due to the amount of time that has passed, regardless of the original check amount.

Please note the member is responsible for ensuring that their correct mailing address is on file with the Human Resources Department in Workday