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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 medical expenses are covered? How much does the Plan pay? How much is the deductible? Is there an annual maximum benefit? Does the program cover substance abuse, alcoholism and mental health services? 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 is the Adult Wellness Benefit? 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. [back to top] 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) [back to top] How much does the Plan pay? For expenses incurred on or after July 1, 2007, 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. All expenses incurred prior to July 1, 2007 will be reimbursed at 90% of R&C. 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 examination. There is no deductible for hearing aids or audiometric examinations. [back to top] How much is the deductible? Members who purchased the City’s drug rider or comparable coverage: For expenses for services incurred prior to July 1, 2007, there is no deductible. For expenses for services incurred from July 1, 2007 through December 31, 2007 there is a deductible of $250 per individual, $500 for two individuals and $750 for three or more individuals. For expenses for services incurred on or after January 1, 2008. 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: For expenses for services incurred prior to July 1, 2007, there is a deductible of $2,000 per individual, $4,000 for two individuals and $6,000 for three or more individuals. For expenses for services incurred from July 1, 2007 through December 31, 2007, he or she must still satisfy the $2,000 per person deductible and are also subject to additional dedutible amounts of $250 per individual and $750 for three or more individuals. For expenses for services incurred on or after January 1, 2008, 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. [back to top] Is there an maximum benefit? There is a lifetime maximum benefit of $1,000,000. Please refer to the SMMP section of the Fund’s Benefits Booklet for details. Download the Fund Benefits Booklet (PDF) [back to top] Does the program cover substance abuse, alcoholism and mental health services? Yes. However, please note that treatment for these conditions as an inpatient at a hospital requires "pre-certification." The SMMP Section of the Fund's Benefits Booklet provides details that are specific to treatment for these conditions such as annual maximum benefits, deductible requirements, and maximum number of visits to a doctor as an outpatient. Download the Fund Benefits Booklet (PDF) [back to top] How do I submit SMMP claims? First, submit medical bills to your other health plans 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 an optional prescription drug rider, you must provide a plan description detailing the prescription drug plan in effect when then service was incurred. Next, compile all itemized bills generated from your service providers and the corresponding Explanation of Benefits (EOB) statements provided by your primary health plan(s). Once you have accumulated out-of-pocket medical 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) [back to top] 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. [back to top] 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. [back to top] How much is the Adult Wellness Benefit? The maximum annual benefit payable for a covered person is $800. Benefits are reimbursed at 100% of Reasonable and Customary (R&C) Allowances. This benefit is not subject to the SMMP deductible. [back to top] How do I submit Adult Wellness Benefit claims? You must first submit claims to your primary health carrier and to any other carriers 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) [back to top] 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) [back to top] 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 [back to top]

Employee Assistance Programs (EAPs)
EAPs are staffed by professional counselors who can help employees and their eligible dependents handle problems in areas such as stress, alcoholism, drug abuse, mental health, and family difficulties.

Learn More

	PICA Program
	NYC Employee Blood Program
	Collective Bargaining Agreements
	OPA Web site
	NYC.gov