SSMC Employee Health Benefit Plan
5
1) All Zip codes in Westchester County, NY
2) These selected Zip codes in Connecticut: 06807, 06830, 06831.
3) These selected Zip codes in the Bronx, NY: 10461, 10462, 10463, 10464, 10465, 10466, 10467,
10468, 10469, 10470, 10471, 10473, and 10475.
Please Note
Some specialized Covered Services and procedures are not available from PHO Providers. If you or your
Dependents require such services, coverage will be provided at PHO Network levels. Before seeking this treatment,
be sure to confirm with the Claims Administrator that the service or procedure is not available in the PHO Network.
The Claims Administrator's phone number is listed in the Introduction section and on your Plan identification card.
3. Reduced Cost Providers. When you do not use a PHO Provider, you may use a POMCO/Multiplan
Allied Network Provider to receive covered services at reduced costs. This service is available for Covered
Persons living in or out of the PHO area. The POMCO/Multiplan Allied Network Providers have an
agreement with POMCO to bill at negotiated rates or scheduled allowances for Covered Services. The
Out-of-Network Plan Deductibles and Percentage Copayment will apply to the reduced charges. You
may phone POMCO for Providers near you or access the Provider list on the POMCO Website:
www.pomco.cc. You should confirm with the Provider whether or not they currently participate in the
POMCO/MultiPlan Allied Network.
4. Allowable Fees. All benefit determinations are based on Allowable Fees for covered services and
Supplies. You are responsible for any charges not covered by the Plan.
a. Out-of-Network Providers. Allowable Fees mean the usual, customary and reasonable (UCR)
charges, as decided by the Claims Administrator, for Covered Services or Supplies rendered and billed
by Network or Out-of-Network Providers. If using a POMCO/Multiplan Allied Provider, the
Allowable Fee shall be the negotiated or scheduled rate for the covered services. The Covered
Expenses must be Incurred by a Covered Person while eligible for Plan coverage. If you or your
Eligible Dependents use an Out-of-Network Provider, you will be responsible for the payment of
charges that are more than the UCR allowance, if any, plus applicable Plan Deductibles and Percentage
Copayment amounts. Out-of-Network means expenses by a Provider who does not have an agreement
with the participating Provider networks.
b. Network Participating Providers. Allowable Fees mean the scheduled Network allowance for
Covered Services or Supplies rendered and billed by Providers who participate in the PHO. A
Covered Person must incur the Services or Supplies while eligible for Plan coverage. The PHO
Network Provider has an agreement with the Plan Administrator to bill for covered services and
Supplies according to the Network negotiated allowance or schedule of allowances. If you use a PHO
Network Provider, you will be responsible only for Deductibles and Copayments. The Provider
cannot balance bill more than the Network Allowable Fees.
5. Free Choice of Providers. You or your Dependents may seek medical care from any Network or Out-of-
Network Health Care Provider, regardless of where you live. This Plan does not restrict specialist care to
primary Physician referral. If a Covered Person seeks treatment from a Physician specialist, Covered
Expenses will be considered even if not referred by a primary or family Physician. This Plan does not
require that you use a member Hospital for your care. The Plan does not impose any emergency conditions
to your choice of Providers.
6. Maternity Care. Maternity or Pregnancy care is covered the same as any other Illness for Employees and
Dependent Spouses including, but not limited to, childbirth and other termination of Pregnancy.
Maternity coverage is not available for Dependent children. The Plan excludes services and Supplies
related to surrogate Pregnancies.
