SSMC Employee Health Benefit Plan
7
Out-of-Network Providers
Schedule A
Deductibles and
Copayments
PHO Area Network Providers
Living In PHO Area
Living Out of PHO Area
Inpatient Deductible
(Deductible applies to
Inpatient facility only)
SSMC / Westchester Medical
Center
Individual: $100 each Covered
Person per Calendar Year.
Family Limit: $300 for three or
more family members per Calendar
Year.
Other PHO Area Hospital or
Substance Abuse Facility:
Individual: $300
Family Limit: $900
Does not Apply
Does Not Apply
Individual: $800 each
Covered Person per
Calendar Year for any
combination of covered
Preventive, Hospital or
Medical Expenses.
Family Limit: $2400 for
three or more family
members per Calendar
Year.
Individual: $100 each
Covered Person per
Calendar Year for any
combination of covered
Preventive, Hospital or
Medical Expenses.
Family Limit: $300 for
three or more family
members per Calendar
Year.
Calendar Year
Deductible
The Plan will not exceed
the Out-of-Network
PHO Area individual or
family limits for any
combination of PHO
Area and Outside PHO
Area expenses.
Does not Apply
Carryover: Allowable Fees Incurred against the
Deductible during October, November and December
reduce the Deductible for the next Calendar Year. This
carryover is based on date expense was Incurred not
when expense submitted.
Percentage
Copayment
The Plan will not
exceed the Out-of-
Network PHO Area
individual or family
limits for any
combination of PHO
Area and Outside PHO
Area expenses.
Inpatient Facility Expenses
SSMC:
After Deductible, Plan pays 100%
of Allowable Fees.
PHO Area Network:
After Deductible, Plan pays 80% of
Allowable Fees up to Out-of-Pocket
maximum then pays 100% for the
remainder of the Calendar Year.
20% Out-of-Pocket Maximum:
Westchester Medical Center:
$600 per Calendar Year for each
Covered Person and not more than
$800 per family.
Other PHO Network Providers:
$1000 per Calendar Year for each
Covered Person and not more than
$2500 per family.
After Deductible, Plan
pays 70% of Allowable
Fees up to Out-of-Pocket
Maximum then pays
100% for the remainder
of the Calendar Year.
30% Out-of-Pocket
Maximum: $3000 each
Covered Person per
Calendar Year and not
more than $6500 per
family.(Any Combination
of Preventive, Hospital or
Medical Expenses)
After Deductible, Plan
pays 80% of Allowable
Fees up to Out-of-Pocket
Maximum then pays
100% for the remainder
of the Calendar Year.
20% Out-of-Pocket
Mmaximum: $600 each
Covered Person per
Calendar Year and not
more than $800 per
family.(Any Combination
of Preventive, Hospital or
Medical Expenses)
