SSMC Employee Health Benefit Plan
9
Schedule A Hospital Expense Benefits (HEB)
Infertility/Reproductive Care Calendar Year Maximum: $10,000 per Calendar Year for any combination of Network or Out -of-
Network Hospital or Medical Expense Benefits (Coverage limited to an approved plan of Outpatient care).
Remember: Benefits could be reduced if you or your Dependent fails to follow the mandatory phone call procedures for most Inpatient
admissions. See Section III - Benefits Management Program for details. All payments are based on Allowable Fees.
Out-of-Network Providers
Schedule A
Hospital Expense
Benefits
SSMC/PHO Area Network
Providers
Living in PHO Area
Living Outside PHO Area
Acute care expenses are covered for unlimited days when found Medically Necessary
according to Plan provisions. Covered Expenses are subject to the Inpatient Deductible
and Percentage Copayments shown below. Private room charges are limited to the
Average Semi-private Room Rates. See separate benefit limits for Mental Illness
Inpatient Care.
Acute Care Hospital/
Birth Center
Inpatient Care
SSMC: After Inpatient
Deductible, Plan pays 100%.
Area PHO Provider: After
Inpatient Deductible, Plan
pays 80%.
After Deductible, Plan
pays 70%. (If emergency
admission, Plan pays at
PHO Provider level.)
Exception: If the Covered
Inpatient Services are not
available at PHO facility,
Plan pays at PHO level.
Plan pays 100% for the
first 120 days per Period
of Confinement, then
after Deductible, Plan
pays 80%.
Medical Emergency Care is initial care rendered within 12 hours after onset of sudden and
serious Illness or treatment of Injury started within 72 hours of an accident and Incurred
within 90 days following the accident.
Outpatient Hospital,
Emergency Care Center,
Urgent Care Facility.
Medical Emergency
Plan pays 100%
No Deductible. Plan pays 100%
Outpatient Hospital
Pre -Admission Tests
Plan pays 100%
After Deductible, Plan pays 100%
Plan pays as Medical Emergency shown previously, if criteria met.
Outpatient Hospital,
Urgent Care Facility,
Ambulatory Surgical
Facility or Similar
Facilities.
Surgical Services
Plan Pays 100%
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Outpatient Hospital
Radiation Therapy,
Chemotherapy
Plan pays 100%
No Deductible, Plan pays 100%
Diagnostic X-ray, Lab
or Machine Tests
Plan pays 100%
No Deductible, Plan pays 100%
Kidney Dialysis
Plan pays 100%
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Other Covered Services
Plan pays 100%
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
