SSMC Employee Health Benefit Plan
4
SECTION I - SUMMARY OF BENEFITS
The benefits shown in this SPD are available to eligible and enrolled Employees and their eligible and enrolled
Dependents (Covered Persons). Please refer to Section II - Eligibility and Enrollment for eligibility
requirements. Benefit Schedules are based on the Employee job classification.
A. Summary
The following summary is a brief outline of the maximum amounts or special limits that may apply to benefits
payable under the Plan. For a detailed description of each covered service, please refer to Section IV -
Covered Services, Section VII - Plan Exclusions, and Section X - Definitions. Benefits are payable based on
two separate schedules, Schedule A Benefits or Schedule B Benefits. The benefit schedule applicable to you is
based on your eligible Employee classification.
B. Schedule A Benefits
1. Classification Covered Persons. Schedule A Benefits are available for the following eligible and enrolled
persons only:
a. Full-time Employees and their Dependents. Coverage includes Preventive Care Expense Benefits,
Hospital Expense Benefits, Medical Expense Benefits and Prescription Drug Expense Benefits.
b. Part time Employees, 30 but less than 37.50 hours per week and their Dependents. Coverage
includes Preventive, Hospital and Medical Expense Benefits. After five full years of eligible
employment, Prescription Drug Expense Benefits become available.
c. Part-time Employees, 22.50 but less than 30 hours per week. Coverage includes Preventive,
Hospital, and Medical Expense Benefits. After five full years of eligible employment, Dependent
coverage becomes available. Coverage is not available for Prescription Drug Expense Benefits.
2. PHO Network. The Physician Hospital Organization (PHO) is comprised of participating Hospitals, other
facilities and participating Physicians who have agreed to participate in the plan PHO. These PHO Network
Providers accept a negotiated or scheduled allowance for their services. If you use a PHO Provider, you
save costs for yourself and SSMC. With regard to Covered Expenses, you need only pay the applicable
Inpatient Deductible and a minimal Copayment for Inpatient and office visits. The PHO Providers bill the
Plan directly and are paid directly. You do not have to submit claims. You will be provided with a current
list of PHO Providers when you enroll in the Plan, free of charge. Updated lists will be provided
periodically. However, at the time of a covered service, it is your responsibility to clarify that the Provider
is still participating in the PHO Network.
a. Using a PHO Provider. If PHO Providers are used, PHO Network benefits apply for you or your
Eligible Dependents.
b. Not using a PHO Provider. If PHO Providers are not used, then the Out-of-Network Plan benefits
apply. These benefits are determined based on whether the Covered Person (including Dependent
students) lives in the PHO area or outside the PHO area. Should you or your Dependent use a non-
PHO Provider, the Out-of-Network Deductible and Percentage Copayments will apply.
c. PHO Area. If a PHO Provider is not used, you or your Dependents are eligible for the Out-of-
Network Plan benefits. Benefit determinations will be according to whether the Covered Person
(including Dependent students) lives in the PHO area or outside the PHO area. The PHO area is subject
to change. You will be advised should this happen. The current PHO area includes the following ZIP
codes:
