SSMC Employee Health Benefit Plan
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SPOUSE - A person who is the legal husband or wife of an eligible Employee, according to the laws of the
state or other jurisdiction in which the eligible Employee resides.
SUBSTANCE ABUSE - A condition caused by regular excessive compulsive drinking of alcohol or physical
habitual dependence of drugs that result in chronic disorders affecting physical health and/or personal or
social functioning. This does not include tobacco dependence and ordinary caffeine containing drinks.
SUBSTANCE ABUSE FACILITY - An agency or freestanding facility or a Hospital center that is certified
by the New York State Office of Alcoholism and Substance Abuse Services (OASAS) for the Outpatient
treatment of Substance Abuse (drugs and alcohol). For services given outside New York, the facility must be
certified by a state agency similar to the New York State OASAS. If a state does not have a certification
regulation, the facility must be approved by the Joint Commission on Accreditation of Health Care
Organizations for the Outpatient treatment of Substance Abuse.
SUPPLIES - Drugs, medicines, devices, appliances, equipment, braces, casts, Prosthetics, materials, or other
items manufactured and used for medical care.
SURGERY - Any of the following:
1. To incise, excise or cauterize any organ or body part;
2. To repair, revise or reconstruct any organ or body part;
3. To treat or to reduce by manipulation a fracture or dislocation;
4. Using endoscopy to diagnose or explore for or to remove a stone or other object from the larynx,
bronchus, trachea, esophagus, stomach, intestine, urinary bladder or ureter;
5. An injection for contrast media testing.
6 Other procedures may be considered if deemed such by the Claims Administrator.
URGENT CARE FACILITY OR EMERGENCY CARE CENTER - A legally operated emergency clinic
or center that meets the requirements in the jurisdiction of license to provide Outpatient Emergency Medical
Care or emergency minor Surgery, but in no way is owned or operated by a Hospital. It must be a facility that
is primarily engaged in providing minor emergency and episodic care to a Covered Person. A qualified
Physician, a registered nurse, and a registered x-ray technician must be in attendance at all times that the
center is open. The center must have on the premises, x-ray and lab equipment and a life support system. A
clinic, center, or facility meeting these requirements will be considered an Urgent Care Facility or center by
whatever actual name it might be called.
USERRA - The Uniformed Services Employment and Reemployment Rights Act, a federal law.
USUAL, CUSTOMARY AND REASONABLE CHARGE - The lowest of:
1. The actual charge for the Covered service or supply;
2. The usual charge by the Physician or other Provider for the same or similar service or supply; or
3. The usual charge of other Providers in the same or similar geographic area for the same or similar service
or supply (prevailing fee).
In the determination of benefits for a claim, the usual level of charges may be modified by a relative value
study, where appropriate, to model actual claims experience in a given area across a range of percentiles. The
term "area" as it would apply to any particular service, medicine, or supply means a zip code, county or such
greater area as is necessary to obtain a representative cross section of level charges. The part of the cost that
exceeds that of any other services that would have been sufficient to safely and adequately diagnose or treat
an individual's physical or mental condition will not be deemed as usual, customary or reasonable charges.
The Claims Administrator makes the determination of the Usual, Customary and Reasonable Charges for
Covered Services or Supplies based on the above rules.
WAITING PERIOD - The designated period between the Employee's date of eligible employment and the
date the Employee becomes covered for Plan Benefits.
