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FAQs
Management Benefits Fund > Superimposed Major Medical Plan


What kind of coverage is offered under the MBF Superimposed Major Medical Plan (SMMP)?
What is a Summary of Benefits and Coverage (SBC)?
What medical expenses are covered?
How much does the Plan pay?
How much is the deductible?
How do I submit SMMP claims?
What is covered under the Adult Wellness Benefit under the SSMP?
What is the purpose of the Adult Wellness Benefit?
How much does the Adult Wellness Benefit pay?
How do I submit Adult Wellness Benefit claims?
How do I obtain claim forms?
Will I lose coverage when I am no longer a member of the MBF?

 

What kind of coverage is offered under the MBF Superimposed Major Medical Plan (SMMP)?
The SMMP is a last-payer type plan intended to supplement your basic City health insurance coverage by providing you additional coverage when you incur substantial out-of-pocket medical expenses.

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What is a Summary of Benefits and Coverage (SBC)?
The SBC is a summary of the benefits and coverage available through the Superimposed Major Medical Plan (SMMP).  It outlines coverage for some of the services, as well as the limitations and cost-sharing that apply to those services.  

The coverage examples on the last page are for illustrative purposes only, and are based on the assumption that the primary health plans and all other health plans have already paid their benefits.  For more detailed information about what is or is not covered under the SMMP, please refer to the SMMP Section of the MBF Benefits Booklet, by clicking on the link below.

Download the SBC (PDF)

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What medical expenses are covered?
Covered charges include doctor's fees for diagnosis, treatment and surgery for illness or injury, hospitalization, etc. A list of covered and non-covered charges appears in the SMMP Section of the MBF Benefits Booklet.

Download the Fund Benefits Booklet (PDF)

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How much does the Plan pay?
For expenses incurred after you satisfy the deductible, reimbursement will be made at 90% of Reasonable and Customary (R&C) allowances for medical services, and 80% for prescription drugs.  Once a covered person reaches the out-of-pocket maximum of $2,500, reimbursement will be made at 100% of the R&C allowances.

Charges incurred toward hearing aids and audiometric examinations are reimbursed subject to a maximum of $1,500 per hearing aid and 90% of R&C allowances for audiometric examinations. There is no deductible for hearing aids or audiometric examinations.

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How much is the deductible?
Members who purchased the City’s drug rider or comparable coverage:

  • There is a deductible of $500 per individual, $1,000 for two individuals and $1500 for three or more individuals.

Members who do not have the City’s prescription drug rider or comparable coverage:

  • There is a deductible of $2,500 per individual, $5,000 for two individuals, and $7,500 for three or more individuals.

An aggregate family maximum will be applied to each deductible level for family consisting of three or more covered persons.  The member and/or the dependent not enrolled in a prescription drug plan offered by the City, should submit documentation of their prescription drug plan to the SMMP Claims Administrator for determination of comparable coverage.

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How do I submit SMMP claims?
First, submit medical bills to your other health plan(s) for payment (or to apply charges toward a deductible or co-insurance). If you are covered under both the City's Health Benefits Program and a spouse's plan (or a plan through other employment), the medical bills must be submitted to both plans before the SMMP.

If your primary plan is a non-city health plan with a prescription drug Plan, you must provide a plan description of the drug plan in effect when the service was incurred.

Next, compile all itemized bills generated from your service providers and the corresponding Explanation of Benefits (EOB) statements provided by your other health plan(s). Once you have accumulated out-of-pocket medical and/or prescription grug expenses equal to or in excess of your SMMP deductible, submit all documentation, including proof of payment, with an SMMP Claim Form for processing.

Contact:
MBF SMMP Claims

Administrative Services Only (ASO), Inc.
PO Box 9009
Lynbrook, NY 11563-9009
Toll free: (877) 844-SMMP (7667)

Download the SMMP Claim Form (PDF)

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What is covered under the Adult Wellness Benefit under SMMP?
The benefit is for annual and/or periodic physical and screening examinations. All covered services will be specific to age, gender, and individual medical history.

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What is the purpose of the Adult Wellness Benefit?
The goal of the program is to promote prevention, early detection, and early intervention before a serious disease develops or advances to a stage where the prognosis is poor and treatment is ineffective. Also, early intervention can result in a reduction in health care cost over years.

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How much does the Adult Wellness Benefit Pay?
Benefits are reimbursed at 100% of Reasonable and Customary (R&C) Allowances. This benefit is not subject to the SMMP deductible.

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How do I submit Adult Wellness Benefit claims?
You must first submit claims to your primary health plan and to any other plan under which you and your spouse/domestic partner have other coverage. (For further details about how claims should be submitted, refer to the back of the SMMP Claim Form.)

Download the SMMP Claim Form (PDF)

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How do I obtain claim forms?
You can download a claim form here or call the Fund's Administrative Office at (212) 306-7290.

Download the SMMP Claim Form (PDF)

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Will I lose SMMP coverage when I am no longer a member of the MBF?
If coverage for you and/or your dependents ends, you may be able to continue coverage under COBRA for a specified period of time.

Find out more about COBRA

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