SSMC Employee Health Benefit Plan
12
Remember: Benefits could be reduced if you or your Dependent fails to follow the mandatory phone call procedures for
most Inpatient admissions or before home care starts. See Section III Benefits Management Program for details.
All payments are based on Allowable Fees.
Out-of-Network Providers
Schedule A MEB
Covered Services
SSMC / PHO Area
Network Providers
Living in PHO Area
Living 0utside PHO
Area
Physician Outpatient
Visits or Treatment
(office, Hospital or other
facility)
See separate benefits for
Outpatient Mental Illness
Care.
$5.00 Network Copayment per
visit.
(Copayment does not apply
to therapeutic injections or
allergy immunotherapy)
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Coverage is limited to 20 visits per Calendar Year for any combination of Network and
Out-of-Network Providers. Coverage includes eating disorders.
Outpatient Mental Illness
Care
$5.00 Network Copayment
per visit up to 20-visit limit.
After Deductible, Plan pays 50% up to 20-visit limit.
Balance does not count toward Out-of-Pocket
maximum.
Coverage limited to intermittent part-time visiting nurse when ordered by the Physician
and found Medically Necessary.
Visiting Nurse
$5.00 Network Copayment
per visit
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
Benefits are based on a Calendar Year period for each Covered Person. Private duty
nursing must be ordered by the attending Physician and found Medically Necessary for
acute care. The first week is excluded, then Plan pays the 2nd through 5th week. Six
weeks or more are excluded. Plan payments are based on Allowable Fees. Network
Providers can balance bill up to Network allowance.
Private Duty Nursing
Percentage Balance does not
count toward Out-of-Pocket
limits.
1st week: No Payment
2nd week: Plan pays 25%
3rd week: Plan pays 50%
4th week: Plan pays 75%
5th. week: Plan pays 100%
6
th
week & after: No payment
Provider can balance bill up
to PHO allowance.
No Deductible. Percentage Balance does not count
toward Out-of-Pocket limits.
1st week: No Payment
2nd week: Plan pays 25%
3rd week: Plan pays 50%
4th week: Plan pays 75%
5th. week: Plan pays 100%
6th week & after: No payment
Physical /Occupational
Therapy
$5.00 Network Copayment per
visit.
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
After 15 visits, the Claims Administrator must pre-approve coverage. Medical records
will be requested from the Provider.
Chiropractic Care
$5.00 Network Copayment
per visit.
After Deductible, Plan
pays 70%
After Deductible, Plan
pays 80%
