SSMC Employee Health Benefit Plan
95
by their employed health care professionals who are licensed and rendering a covered service within the
scope and jurisdiction of their license); any legally licensed podiatrist, chiropractor, registered professional
nurse, certified nurse midwife, Certified Acupuncturist, optometrist, audiologist, physical therapist, speech
therapist, podiatrist, chiropractor, clinical psychologist, Certified Mental Health Nurse, Certified Mental
Health Social Worker or Certified Substance Abuse Counselor rendering a covered service within the scope
and jurisdiction of their license; any independent laboratory, Pharmacy, Hospital, Skilled Nursing Facility,
Substance Abuse Facility, Hospice Agency, Home Health Care Agency; or other facility/agency included for
Plan coverage. Coverage includes charges billed by Urgent Care Facilities, and other health centers or clinics
for Covered Services given by Covered Physicians or other Professional Healthcare Providers that would
otherwise be Covered by the Plan. Also, see definitions for certain Providers. To be covered, a Provider must
meet Plan definitions and limitations, render a Covered service within Plan limitations, be operating within
the scope of their applicable certification and license, and operating according to the laws of the jurisdiction
where Services or Supplies are given or delivered.
PSYCHIATRIC FACILITY - A private facility (not government owned) that has been accredited by the
Joint Commission on Accreditation of Health Care Organizations as an Inpatient facility for the treatment of
Mental Illness and is licensed by appropriate state agencies; or a facility that provides residential care and
treatment for emotionally disturbed children and adolescents that has been accredited by the Joint
Commission on Accreditation of Health Care Organizations or the American Association of Psychiatric
Services for Children as a residential treatment facility and is licensed by appropriate state agencies; or a
public (government owned) mental health facility that usually bills for its services.
REHABILITATIVE OR REHABILITATION - Medical treatment intended to restore (bring back) a person
to a former or optimal (best possible) state of health following an Illness or Injury.
REHABILITATION FACILITY - The facility must be approved by the Joint Commission on Accreditation
of Health Care Organizations for Rehabilitation care and a Medicare-approved Rehabilitation Facility
eligible for Medicare Part A benefits. See Skilled Nursing Facility.
RESIDENTIAL TREATMENT FACILITY - See Psychiatric Facility.
ROUTINE NEWBORN NURSERY CARE - Charges made by the caring Hospital or a similar institution
and/or the attending Physician for the Custodial and nursing care, including circumcision, of a Newborn
infant deemed to be free of any identifiable Illness or disease requiring treatment.
SERVICES OR SUPPLIES Medical Services or Supplies included for Plan coverage and found Medically
Necessary according to the Plan provisions, limitations and exclusions. Limited preventive care included for
Plan coverage according to Plan provisions, limitations and exclusions.
SICKNESS - See Illness.
SKILLED NURSING FACILITY - An institution or part thereof that meets one of the following
requirements:
1. The facility or part thereof must be licensed and operating within the jurisdiction of applicable state laws,
if any, and accredited as a Skilled Nursing Facility, by the Joint Commission on Accreditation of Health
Care Organizations; or
2. The facility or part of the facility (including a facility referring to itself as an Extended Care Facility,
Rehabilitation Facility or convalescent nursing home or any other similar nomenclature) must be certified
by Medicare as a facility eligible for Medicare Part A Skilled Nursing Facility benefits.
SOUND NATURAL TEETH - Natural teeth that are fully restored to function; or do not have any decay; or
that are not more susceptible to Injury than virgin teeth; or do not have significant periodontal disease.
