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8-23-2010
Important Medical Coverage Available to Managers - SMMP

Important Medical Coverage Available to Managers

The Management Benefits Fund (MBF) offers active and retired managers a significant benefit through the Superimposed Major Medical Plan (SMMP) at no cost to the member.

The SMMP will reimburse for deductibles, co-pays and other eligible expenses not covered by city health insurance plans that are incurred by the manager, spouse or eligible dependent, subject to an annual deductible.

Expenses that can be reimbursed include services from medical providers (such as doctors), mental health services (such as psychotherapy), surgery, radiology, laboratory tests, hospital services, durable medical equipment, orthotics, acupuncture and prescription drugs.

This document is not a complete explanation of the SMMP and is not intended as such. Complete SMMP information can be obtained by clicking on the “links” tab on the homepage of this website, www.nycmea.org, and then on the Management Benefit Fund link. Questions can also be addressed to ASO, the plan’s administrator, at 877-844-7667.

Deductibles and Benefits

The calendar year deductible per is $500 for an individual, $1000 for manager and spouse, and $1,500 for families of three or more. The deductible for managers who do not have the optional prescription drug rider is $2,500 per individual, $5000 per couple or $7,500 for a family of three or more.

The plan reimburses 90% of “reasonable and customary” costs for covered medical expenses not paid by health insurance after the deductible is met. It reimburses 80% of prescription drug costs not covered by health insurance.

If the member accumulates $2,500 in out-of-pocket expenses (not including the deductible), the SMMP will reimburse 100% of reasonable and customary expenses for the duration of the calendar year.

There is an oral and dental surgery benefit for certain surgical procedures not covered under the MBF’s dental benefit and a benefit for accidental injury to teeth, jaw, mouth and face. The SMMP coverage is separate from the coverage under the Management Benefit Fund’s Dental Benefit and is somewhat vaguely defined in the MBF’s official plan description. Contact ASO, 877-844-7667, for guidance in specific situations.

Not subject to the SMMP annual deductible is a hearing aid and audiometric exam reimbursement of up to $1,500 for the hearing aid and 90 percent of reasonable and customary for the exam every two years.

Also exempt from the SMMP deductible is an adult “wellness” benefit which will reimburse up to $800 annually for a physical exam, certain diagnostic procedures, certain inoculations and nutritional counseling. The official plan benefit description does not list all the diagnostic procedures for which reimbursement is available. Address specific questions can be addressed to ASO, 877-844-7667.

Covered by an HMO?

Members insured by HMOs 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. The same deductibles are applicable.

Covered by Medicare?

Managers insured by Medicare are eligible for the SMMP with one major caveat: the medical services provider must accept Medicare. If the member chooses to see a provider for medical services who does not accept Medicare, the member will not be reimbursed by Medicare, the city’s Medigap policy or by the SMMP.

Drug coverage for Medicare recipients is limited to reimbursement of the five percent (5%) copay required of members who reach the “catastrophic” level of prescription drug coverage of Medicare Part D.

The SMMP Can Limit Your Medical Expenses

The SMMP can limit a manager’s exposure to medical expenses. After the cost of the drug coverage riders and after the SMMP’s deductible is met, the member pays no more than 10 percent of every other covered out-of-pocket cost (20 percent for prescription drugs).

For hypothetical example, a member with GHI sees a medical provider who charges $200. GHI reimburses the member according to the GHI scale, which, for purposes of this example, let’s say is $50. The SMMP will reimburse the member $135 (e.g., 90 percent of $200-$50), assuming the member has met the annual deductible. The member’s net cost in this example is $15, which can be tax deductible.

Claims Submission

Claims must be submitted within 24 months from the date of service. The filing process is very paper intensive: attention must be paid to the details. Claims must include all of the following:

- An invoice from the provider that shows the diagnostic code and CPT procedure code (two separate codes). Some providers do not routinely provide this information on invoices given to patients and it may have to specifically be requested. A copy of the claim the provider sends to the primary insurance company or to Medicare will have these codes and is sufficient for SMMP purposes.

- A copy of all explanations of benefits. For most managers, this is the GHI EOB. For members covered by Medicare, this means the Medicare Summary Notice (MSN) and the EOB from the manager’s Medigap policy.

- Proof that you paid the bill. This means a copy of your credit card bill, cancelled check, receipt or the like.

- A signed and dated SMMP claim form.


  
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