Annual Physical Benefit

SASMI’s Annual Physical Benefit encourages you and your family to stay on top of your preventive care. Members can receive $200 per calendar year for their own physical exam and $100 for covered family members (up to a maximum of $600 total per family, per calendar year), just for getting a routine checkup. If you need to miss work to get your exam or if you have out-of-pocket incidental expenses, this benefit can help replace any income you’ve lost.

While health plans cover many preventive care services at 100% under the Affordable Care Act, there may be additional costs associated with a routine physical (like certain tests and screenings as well as mileage and time away from work) that may not be covered. That’s when the Annual Physical Benefit may come in handy.

Eligibility

To be eligible for the Annual Physical Benefit, you must be eligible for SASMI benefits both during the stabilization period in which you (or your spouse or child) get the exam or screening and at the time you apply for the benefit. You must be covered by a welfare plan maintained under your collective bargaining agreement, but you are eligible to receive this SASMI benefit even if your welfare plan covers your exam in full — as most do.

For your spouse or children to be eligible, they must be covered as a dependent under the welfare plan maintained under your collective bargaining agreement.

You must be an active member and eligible for the benefit both at the time you (or your family member) get the preventive care and at the time you apply for the benefit.

Benefit Amount

Benefit amounts are per calendar year and depend on whether the person getting the exam is a member, spouse or dependent. The maximum amount you can receive for your family in a calendar year is $600. Your benefit will be directly deposited into your bank account.

What’s Covered?

For purposes of this benefit, a physical examination is a routine test your primary care provider (PCP) or OB/GYN performs to check your overall health. A PCP may be a doctor, a nurse practitioner, or a physician assistant. The exam is also known as a wellness check.

An annual physical exam may be a general annual physical exam, a well woman exam, or an annual well child exam. The exam may include:

• A comprehensive review of systems, including the cardiovascular system, respiratory system, musculoskeletal system, etc.
• A well woman exam, a pap smear, or a screening mammogram
• A PSA exam, for males
• A screening colonoscopy or other colorectal screening test
• A multi-system physical examination based on the patient’s age, gender, and identified risk factors
• Any age-appropriate counseling and risk factors assessed

It does not include annual eye exams, dental cleaning and routine visits, or routine follow-up visits after a medical incident such as a follow-up with a cardiologist or oncologist or dermatologist. It is not a visit for treatment of an illness or injury or that is scheduled because you are having symptoms of an illness or injury.

What You Need To Do

Once you get your checkup or screening, you have 12 months from the date of service to claim your benefit. If you submit your application for the benefit after December 15, it will not be processed until the next calendar year. To get started:

• Log in to the member portal and click on “Applications” and then “Annual Physical Benefit” to access the form.
• Complete the online form.
• Upload a copy of your SMART-affiliated health and welfare fund’s Explanation of Benefits (EOB) that shows that you (and/or your family member) received the preventive care from a qualified professional.
• Provide your bank routing information for direct deposit.

You’ll be notified via email once the benefit has been deposited into your bank account.

If Your Claim for the Annual Physical Benefit Is Denied

If your claim is denied, you’ll receive a letter stating the reason for the denial. If your Annual Physical Benefit claim was denied, it may be because you:

• Had one too recently (it’s only offered once every calendar year),
• Did not provide a copy of the Explanation of Benefits (EOB) that shows you received the preventive care from a qualified professional,
• May not have met all the eligibility requirements—you must be eligible for SASMI benefits both during the stabilization period in which you get the physical exam and at the time you apply for the benefit,
• Did not submit your claim within 12 months of the date you received the exam, or
• You’ve already received benefits from SASMI equal to or more than the contributions paid by your employers (100% rule).

Frequently Asked Questions