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The information provided in the following pages primarily addresses health plan provisions for the Cleveland Clinic Employee Health Plan (EHP). Summaries of the SummaCare Health Plan EPO (Exclusive Provider Organization) and Kaiser Permanente HMO (Health Maintenance Organization) offerings for the 2009 calendar year are provided as well. Current employees have the opportunity each year to re-enroll for their coverage through the BeneFlex Open Enrollment process. Through this process, you can choose to keep the same coverage you have or make changes to it for the coming calendar year.

Two-Tier Network

The Cleveland Clinic Employee Health Plan (EHP) offers a two-tier Network of Providers. Cleveland Clinic and Regional hospitals, including participating physicians, comprise the Tier 1 Provider Network and Cleveland Health Network (CHN) is the Tier 2 Provider Network. Both networks are credentialed through the Community Physician Partnership (CPP). As a Cleveland Clinic EHP member, you can use either provider tier at anytime throughout the benefit year and may see providers in both tiers if you choose. The tier you select, however, determines the amount of coverage you will receive. To receive maximum coverage, you must use Tier 1 Providers.

Tier 1 includes all Cleveland Clinic and Regional hospital providers in the CPP and are, for the most part, located in Cuyahoga County. The Tier 1 Cleveland Clinic EHP Network of Providers includes Primary Care Providers (PCP), Specialist Providers (SP), Behavioral Health Providers, and Ancillary Services Providers. Ancillary Services are services such as dialysis, ambulance transportation, durable medical equipment (DME), home health, skilled nursing facilities, hospice and others.

Tier 2 consists of three provider networks:

  • Cleveland Health Network (CHN) - a regional network of hospitals, physicians, and other healthcare providers in northern Ohio and western Pennsylvania.
    Web site: www.chnetwork.com
  • Medical Mutual Traditional Network - a network of providers within the state of Ohio.
    Web site: www.supermednetwork.com and click on “Traditional".
  • USA Managed Care Organization (USAMCO) - a network of providers outside the state of Ohio.
    Web site: www.usamco.com.

All Emergency/Urgent Care services are covered at 100% after a $50 co-payment regardless of the provider of service.

The SummaCare Health Plan EPO (Exclusive Provider Organization) requires you to select one Primary Care Provider (PCP) listed in the Network Provider Directory to be your personal Physician. This is the Physician you will visit for most of your healthcare needs. If your PCP determines that you require care from a specialist, need surgery, or should be admitted to the Hospital or some other facility, he will refer you to an appropriate source for that care and obtain any necessary pre-authorization. Please remember that in order to receive benefits under the Plan, you MUST select a PCP.

Following is a summary of the benefits Cleveland Clinic employees can receive from the SummaCare Health Plan EPO:

  • No deductibles or co-insurance
  • Flat co-payments for office visits ($15 for both primary care and specialists)
  • Prescription drug coverage through the Cleveland Clinic Employee Health Plan Program (CVS Caremark is the Prescription Benefit Manager)
  • Approximately 5,000 Providers complemented by a network of hospitals in 13 counties

The Kaiser Permanente HMO (Health Maintenance Organization) requires your Primary Care Provider (PCP) to authorize all healthcare services before services are rendered, or there is no benefit coverage. Services must be received at a Kaiser Permanente facility.

Following is a summary of the benefits Cleveland Clinic employees can receive from the Kaiser Permanente HMO health plan:

  • No deductibles or coinsurance
  • Flat co-payments for office visits ($15 for both primary care and specialists)
  • Flat co-payments for prescriptions (generic $15; brand $30)
  • Ten Kaiser Permanente medical offices throughout Northeast Ohio
  • Affiliated community physicians practicing in their own offices throughout Northeast Ohio

Third-Party Administrator (TPA)

Cleveland Clinic employees should go directly to the third-party administrator (TPA) for the plan they are enrolled in to resolve any claims payment issues.

  • The Cleveland Clinic EHP TPA is Antares Management Solutions.  The Antares customer service department can be reached by calling 1-800-451-7929.
  • The SummaCare Health Plan EPO customer service department can be reached by calling 330-996-8515 or toll-free at 1-800-753-8429.
  • The Kaiser Permanente HMO customer service department can be reached by calling 1-800-686-7100.

If your problem is not resolved to your satisfaction after calling the TPA directly, please call the Cleveland Clinic Corporate Employee Health Plan Customer Service Unit at 216-448-0800 or toll-free at 1-866-811-4352.

 

 

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