Representatives from the Office of Labor Relations presented on October 15 to our membership. SMMP is a supplemental (last payer type) medical coverage plan. It supplements your health insurance by providing coverage for those members and covered dependents who have qualifying out-of-pocket medical expenses, which remain after all other health coverages have been applied.
All SMMP claims must be submitted directly to ASO
(within 24 months from the date of service)
Administrative Services Only (ASO), Inc.
P.O. Box 9009
Lynbrook, NY 11563-9009
ASO
Phone: 1-877-844-7667
ASO website, HERE.
MBF
Phone: 212-306-7290
MBF website, HERE.
Members submitted questions in advance, see below.
Q: Are you allowed to submit the out-of-pocket bill for Wegovy even if you aren’t covered by the prescription plan?
MBF: No, if prescription drugs are not covered by your primary health plan, then they will not be covered by SMMP.
Q: Can you please discuss how the SMMP can be utilized for family planning expenses, including the process and what’s covered?
MBF: Effective November 1, 2024, the Management Benefits Fund is providing a family building benefit reimbursement to MBF members under the Superimposed Major Medical Program (SMMP), for the following family building expenses up to a maximum of $10,000 per child/attempt to conceive or adopt: Adoption expenses, Surrogacy arrangement expenses, and Purchase of donor material.
Q: Can you use the cost of prescription drugs ordered through a Medicare Part D provider towards the SMMP deductible?
MBF: No, Effective January 1, 2024, Medicare Part D Plans will pay 100% of covered prescription drugs once the Medicare-eligible member and/or spouse or domestic partner reaches the catastrophic level. Therefore, Medicare-eligible MBF members and their Medicare-eligible spouse/domestic partner will not have any out-of-pocket prescription drug expenses once the catastrophic level is reached.
Q: Coverage ends when an individual is no longer an MBF member. Does this apply to retirees and how would membership end?
MBF: MBF coverage would end for a retiree enrolled in MBF upon their death. At that point, their dependents would be eligible for Survivor coverage up to 36 months.
Q: How does my coverage change with retirement in January 2026 and Medicare?
MBF: MBF coverage remains the same, except for SMMP coverage for prescription drugs. Since Medicare Part D plans pay 100% of covered prescription drugs once the MBF member reaches the catastrophic level. Medicare-eligible MBF members and their Medicare-eligible spouse/domestic partner will not have any out-of-pocket prescription drug expenses once the catastrophic level is reached. Furthermore, Basic Life coverage is reduced to $5,000 for all retirees.
Q: How does SMMP reimburse out-of-network expenses?
MBF: If the primary health plan does not cover the medical expenses, then SMMP will not cover the expenses. If the health plan covers the out-of-network medical expense, then SMMP will cover the remaining applicable out-of-pocket costs. Please note that one exception is acupuncture. MBF will reimburse for acupuncture.
Q: If prescription drug coverage is provided under my spouse’s job insurance are the co-pays reimbursable?
MBF: MBF members covered under a non-City group health plan are eligible to submit their claims/out-of-pocket costs to SMMP for reimbursement.
Q: Are there any implications for not maintaining Emblem’s Senior Care and SMMP reimbursement of cost sharing (20%) and copays?
MBF: After MBF member pays the out-of-pocket expenses once Medicare pays the claim, then members can submit their claims to SMMP for processing, along with the SMMP claim form, proof of payments, EOBs, etc.
Q: Is the coverage period always calculated from the first of the year or from the first date of an incurred cost?
MBF: The SMMP benefit runs on a calendar year basis – January to December.
Q: How do you apply for the coverage?
MBF: As long as you are enrolled in MBF, then you are eligible to submit claims to SMMP. Please refer to the MBF benefits booklet in the SMMP section for how to submit claims at nyc.gov/mbf.
Q: What documentation is needed to support a claim for benefits?
MBF: MBF members must submit an Explanation of Benefits for his health plan, invoice from the provider, and the SMMP claim form.
Q: What happens to this benefit (for retirees) if we take out our own supplemental insurance plan?
MBF: SMMP would become tertiary since it is the last payer of out-of-pocket medical expenses.
Q: What happens to this benefit (for retirees) if we’re forced to go on the new Advantage plan?
MBF: Medicare retirees are not forced in any Medicare Advantage plan.
Q: What types of services does this cover?
MBF: Out-of-pocket medical expenses or prescription drugs that are covered by the primary health plan, such as x-rays, diagnostic test, surgery, etc.
Q: When joining a health club mid-calendar year, is there a minimum number of visits per month required for reimbursement?
MBF: The MBF member simply has to submit an MBF Health and Fitness claim form and receipts for any health activity during a 6-month period in order to be reimbursed.
