SSMC Employee Health Benefit Plan
10
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
Inpatient Mental Illness Care is limited to 30 days per Calendar Year and not more
than 90 days per Covered Person's Lifetime.
Mental Illness Inpatient
Care
Acute Care Hospital
Psychiatric Facilities
Plan pays 100% (No Inpatient
Deductible.
After Deductible, Plan pays 50%, (Balance does not
apply to percentage Out-of-Pocket maximums).
Private room charges are limited to Average Semi-private Room Rates
Skilled Nursing Facility
Plan pays 100% (No Inpatient
Deductible)
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Coverage is limited to 40 visits per Calendar Year for any combination of area and out
of area Providers.
Home Health Agency
Plan pays 100%
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Hospice Care
Plan pays 100%
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Inpatient coverage is limited to 30 benefit days each Calendar Year per each Covered
Person. Private room charges are limited to Average Semi-private Room Rates. Benefits
are limited to a maximum of $50,000 for any combination of Inpatient or Outpatient
Substance Abuse care per each Covered Person's Lifetime.
Substance Abuse Facility
Inpatient
After Inpatient Deductible,
Plan pays 100%
After Deductible, Plan pays 50% (Balance does not
count toward Out-of-Pocket maximums)
In addition to the Lifetime benefit maximum shown above and benefit maximum each
Calendar Year shown below, the Plan will not pay more than $1000 each Calendar Year
for any combination of PHO or Out-of-Network Benefits
.
Substance Abuse Facility /
Certified Substance Abuse
Counselor
Outpatient
After $5.00 Network
Copayment per visit, Plan
pays balance of Network
allowance up to $1000 each
Calendar Year per Covered
Person.
After Deductible, Plan pays 50% of Allowable Fees
up to $20 per visit up to benefit maximum of $500
each Calendar Year per Covered Person. (Balance
does not count toward Out-of-Pocket maximums).
Schedule A Medical Expense Benefits (MEB)
(Physicians and other Healthcare Providers)
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).
