Sound Shore Medical Center of Westchester SSMC Active EE Health Final SPD Page 100
SSMC Employee Health Benefit Plan
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OUT-OF-NETWORK PROVIDER- An organization, Physician, Hospital, Pharmacy or other Healthcare
Provider that, at the time Covered Services or Supplies are provided, does not have a contract or agreement
with the Participating Provider Network selected by the Plan Administrator to provide medical Services or
Supplies to the Covered Persons under the Plan for scheduled or negotiated charges or allowances.
OUTPATIENT - Care rendered in the Outpatient or emergency department of a Hospital or other health
facility or care rendered in the Provider's office, patient's home or other care rendered on other than an
Inpatient basis.
PARTICIPATING PROVIDER - See Network Provider.
PARTICIPATION PAYMENT - The portion of the Plan costs that the Plan Administrator or/ Plan Sponsor
collects from Plan Enrollees or participants to provide coverage under the Plan, if applicable.
PERCENTAGE COPAYMENT - See Copayment.
PERIOD OF CONFINEMENT - A Period of Confinement is established for each unrelated Illness or
Injuries from different accidents. A Period of Confinement begins when the patient is admitted to a Hospital
as a bed patient and ends when the patient is no longer a patient in a Hospital, Birth Center, Skilled Nursing
Facility or other covered Inpatient facility or receiving home health care for at least 90 days for the same or
related Illnesses or related Injuries (resulting from same accident). A new Period of Confinement for the
same Illness or Injury begins when 90 days separate the last Inpatient or home health care treatment.
PHARMACY - An establishment operating under and within the jurisdiction of state laws concerning
Pharmacies to dispense prescriptions and where the prescription drugs are dispensed by a licensed pharmacist
within the jurisdiction of the license.
PHYSICIAN - The following who are legally licensed and providing Covered medical services within the
scope and jurisdiction of their license: A medical Doctor (M.D.), osteopath (D.O.); Dentists (D.D.S. or
D.M.D.) for covered dental/medical care; podiatrist (D.P.M) for treatment of the feet; Chiropractor (D.C) for
spinal subluxation; licensed clinical psychologists, Certified Mental Health Nurse or Certified Mental Health
Social Worker for Mental Illness care; certified nurse midwife for maternity care.
PREGNANCY - That physical state of Pregnancy which results in childbirth, abortion or miscarriage. This
definition includes medical complications of the physical state of Pregnancy. Pregnancy or maternity care
will be considered for benefits the same as any other Illness subject to Plan limitations and exclusions.
PROFESSIONAL HEALTHCARE PROVIDER A person licensed under New York State Law to render
or prescribe Services or Supplies covered under the Plan and is operating within the restrictions or scope of that
license. Sometimes, this may require that the Covered Services or Supplies must be ordered by a Professional
Healthcare Provider who is licensed and qualified to evaluate, manage and prescribe drugs or medical treatment
for the Illness or Injury. Outside New York State, licensed Professional Healthcare Providers will be covered
to the extent that they would have otherwise been covered if operating in New York State. Then, the Provider
must be licensed in the state of jurisdiction and giving the Covered service within the restrictions of that
license.
PROSTHETICS - The making and application of any artificial part that replaces all or part of a body part,
organ or function lost or impaired as the result of disease or Injury. This does not include, for example,
eyeglasses or contact lenses, hearing aids, wigs, orthopedic shoes or supportive devices for the feet.
PROVIDER -Any legally licensed medical Doctor, osteopath, dentist, (including their charges for services
