Catastrophic Coverage

This self-funded SBA benefit was established to assist our members and eligible dependents (who are subscribers of a PPO/indemnity or a POS health plan) to defray some of the non-covered medical and surgical expenses incurred for services rendered by non-participating or out-of-network providers.

Eligibility
Active members are eligible, as well as spouses/domestic partners and dependent children who are covered under a participating provider organization (PPO) or a point-of-service (POS) plan presently being offered by the New York City Employee Health Benefits Program.

Definition of PPO and POS
Participating provider organization (PPO) indemnity plans offer the option to use either a network provider or an out-of-network provider for medical and hospital care. PPO plans contract with health care providers who agree to accept a negotiated payment from the health plan and predetermined co-payments from subscribers as payment in full for a schedule of medical services provided. When the subscriber uses a non-participating provider, the subscriber is subject to deductibles and/or a higher price schedule. GHI/CBP is an example of a PPO.

Point-of-service (POS) plans offer the freedom to use either a network provider or an out-of-network provider for medical and hospital care. If the subscriber uses a network provider, health care delivery resembles that of a traditional HMO, with prepaid comprehensive coverage and little out-of-pocket costs for services. When the subscriber uses an out-of-network provider, health care delivery resembles that of an indemnity insurance product, with less comprehensive coverage and subject to deductibles and coinsurance. HIP PRIME POS and U S. Health Care (QPOS) are POS plans.

The SBA H&W Fund catastrophic coverage plan does not cover subscribers of exclusive participating organizations (EPOs) because they do not provide any out of network benefits.

The catastrophic coverage benefit
The benefit pays up to 100 percent of reasonable and customary eligible expenses after a $2,000 out-of-pocket annual deductible per person has been reached. Eligible out-of-pocket expenses are those SBA H&W Fund medical and hospital expense charges that are considered reasonable and customary by the basic City Health Plan and are not fully reimbursed by the City Health Plan or private group insurers.

Benefit limits and maximums
There is a lifetime maximum benefit of $250,000 per covered person. Within this lifetime maximum are the following:

(1) Mental health in-hospital care of $10,000

(2) Required and approved private duty nursing is covered in full for the first unpaid $25,000 and then at 50 percent for the remainder up to a lifetime maximum of $50,000.

Services or charges not covered by the catastrophic benefit
In addition the benefit exclusions of the SBA H&W Fund, the catastrophic benefit does not cover outpatient psychiatric care and prescription drug charges. Ineligible charges such as experimental procedures or services not approved by the member’s health plan are likewise not covered by this benefit. Medical, surgical and hospital charges incurred for services rendered by non-participating PPO providers or out-of-network POS providers must be approved by the member’s health plan.

Submitting an SBA catastrophic benefit claim
Once you have reached the $2,000 out-of-pocket, per-person annual deductible, obtain and submit the catastrophic claim benefit form to the Fund office for processing. Instructions are printed on the form.