Dear MEA Member:
During our recent informational field meetings, we learned that many active managers, as well as non-Medicare eligible retirees (55-64 year olds), are not familiar with their Superimposed Major Medical Plan Benefits (SMMP) and/or the claims submission procedure for reimbursement. Medicare eligible retirees usually have their medical expenses covered by their Medicare plans and may not be eligible for the supplemental benefits provided by SMMP.
The Superimposed Major Medical Plan provides supplemental coverage to members who incur out-of-pocket medical expenses after all other health coverage’s have been utilized. After satisfying the calendar year deductible of $500 for an individual or a family maximum deductible of $1,500 for a family of three or more individuals, the plan reimburses 90% of non-reimbursed covered medical expenses at the Reasonable and Customary Allowances and 80% of non-reimbursed drug costs until out-of-pocket expenses reach $2,500. After you reach $2,500 out-of-pocket expenses, SMMP will reimburse at 100%.
Note: 1) Members who do not have a prescription drug plan/rider have a deductible of $2,500 per individual or a family maximum deductible of $7,500 for a family of three or more individuals.
2) Members covered under HMO plans are required to use the services of HMO providers and can only use SMMP for co-payments or services not available under their HMO plan.
3) Retirees at the time they become Medicare eligible (65 years of age) should pay particular attention to their pre-65 incurred medical and prescription drug out-of-pocket expenses which may be reimbursed by SMMP if they exceed the $500 deductible.
4) SMMP does not provide prescription drug coverage to retired members who are eligible to receive prescription drug benefits through a Medicare Part D Plan. However, SMMP will provide reimbursement for Medicare eligible members for the 5% out-of-pocket expense incurred when a member reaches the catastrophic level of coverage under Medicare Part D. Members seeking this 5% reimbursement must submit to SMMP an "Annual Medicare Part D Catastrophic Co-Insurance Reimbursement Claim Form" together with the annual Explanation of Benefit (EOB) they receive from their prescription drug plan at the end of the year reflecting the 5% co-insurance they paid in excess of that year's maximum catastrophic coverage amount.
Covered services under SMMP may include medical doctor visits, surgery, radiology, laboratory, hospital services, durable medical equipment, orthotics, and prescription drugs. This list is not all inclusive but is provided as a general listing of possible covered charges available under the SMMP benefits.
All out-of-pocket covered medical expenses should be submitted as incurred. In order to be considered for payment, claims must be submitted within 24 months from the date of service.
1) Submit medical bills to your primary health plan for payments (or to apply charges toward a deductible or co-insurance). Members should be aware that co-pays of $10, $15, and $20 can add up and are counted towards satisfying the $500 SMMP deductible.
2) If you are covered under both the City's Employee Health Benefits Program and a spouse's plan (or a plan through other employment), medical bills must be submitted to both plans before you submit to SMMP.
3) Collect all itemized bills generated from your medical provider. Make sure the bills contain the diagnosis codes and CPT procedure codes.
4) Collect the Explanation of Benefits (EOB) statements provided by all health plans under which you have coverage in reference to the above itemized bills.
5) Include proof of payment (cancelled check, receipt, etc.) for out-of-pocket expenses.
6) Complete the SMMP claim form.
7) Submit all claims with the proper documentation to:
MBF SMMP Claims
Administrative Services Only (ASO), Inc.
PO Box 9009
Lynbrook, NY 11563-9009
Toll Free: 1-877-844-7667
Payment will be made to the member, not the provider.
For more detailed information concerning your Superimposed Major Medical Plan benefits (covered services, non-covered services, claim submission, appeal process, etc.) and/or to obtain an SMMP Claim Form, please go the Link on the MEA website – www.nycmea.org and click on Management Benefit Fund which offers the Superimposed Major Medical Plan information.
Joel Fishelson, Chair
MEA Organization Committee