Guide to Supplementary Major Medical Benefit (SMM)

Whether you have employee health benefits or an individual health insurance plan, your insurance provider might offer the optional supplementary major medical benefit (SMM). Find out how the SMM can enhance your coverage and boost your protection.

What is the supplementary major medical benefit?

Offered as an option in some health insurance plans, the supplementary major medical benefit covers expenses that a basic medical plan does not. Once medical expenses exceed the basic plan’s coverage amount, the SMM comes into effect. The SMM covers a set percentage of hospital expenses in excess of the maximum payable hospital benefits after taking into account any applicable deductible or coinsurance and up to the maximum SMM benefit limit.

The SMM reimbursement percentage varies per insurer but is usually around 80%.

What does the SMM benefit cover?

The SMM covers hospitalization expenses such as room and board, attending doctor's visits, specialist consultations, intensive care, surgeon's fees, operating theater charges, hospital companion bed, and more. Some plans may allow you to extend SMM coverage to your dependents.

Who needs supplementary major medical cover?

The SMM benefit may be useful if the coverage limit for the inpatient benefits (also known as hospital and surgical benefits) in your basic medical plan is inadequate for your needs. The SMM can help you significantly reduce the amount you pay out of pocket for medical expenses.

SMM case study

Suppose a person who has group medical insurance with the additional supplementary major medical benefit has had an angioplasty at a private hospital.

• Total medical expenses: HK$ 100,000

• Group medical yearly maximum benefit limit: HK$ 75,000

• SMM reimbursement percentage: 80%

• SMM per disability limit: HK$ 300,000

Without SMM:

• Insurer pays: HK$ 75,000 (benefit limit)

• Patient pays: HK$ 25,000

With SMM:

• Insurer pays: HK$ 95,000 (benefit limit + excess*80%)

• Patient pays: HK$ 5,000

Because the patient has SMM added to their group medical insurance plan, they can avoid paying HK$ 20,000 for out-of-pocket medical expenses.

What to look out for when using the SMM benefit

Pay attention to the sub-limits and caps within your SMM benefit, which vary by insurer and policy. Limits may vary based on age; for example, they may be higher for those under the age of 80 years. You’ll also want to pay attention to this benefit's yearly and lifetime limits.

Moreover, coverage under the SMM for daily room and board, attending doctor’s visits and intensive care might only begin from the 121st day of confinement (i.e., after the inpatient benefit limit has been exhausted) and be capped to a certain amount per day.

Be careful to stick to the hospital room class specified in your benefit schedule, otherwise, the reimbursement percentage applicable for all the excess amounts payable might be reduced, or you might not be reimbursed at all under the SMM benefit.

How to add SMM to your plan

Whether you have a group health insurance plan or an individual plan, if you are interested in the SMM benefit, get in touch with your insurance broker or advisor. They can help you determine if the SMM is available for your plan and guide you through the steps for adding it.

If your plan doesn’t offer SMM as an option, then your advisor can walk you through other alternatives to enhance your protection for peace of mind (such as top-up insurance).