SSMC Employee Health Benefit Plan
15
E. Potential Causes for Benefit Reduction
1. Medicare. Your Plan benefits could be reduced by Medicare payments, if Medicare is considered primary
coverage according to Medicare secondary payer rules. This reduction will apply whether or not the
Covered Person eligible for Medicare is actually enrolled in Medicare. Refer to Section VI - Medicare
Integration with Plan Benefits. Failure to enroll in Medicare when Medicare is primary could result in
significant reduction or denial of SSMC health benefits. You could be responsible for the payment of all or
most of your (or your Dependent's) health expenses.
2. Other Plan/Coordination of Benefits. Your Plan benefits could be reduced if you or your Dependents are
Covered by more than one health plan. Refer to Section VII - Coordination of Benefits.
3. Plan Right of Subrogation/Reimbursement. This Plan specifically does not give benefits with respect to
any Injury or Illness for which a third party may be liable or legally responsible. If you or your Dependents
receive payment or are entitled to payment from a third party insurance, surety or other type plan resulting
from such Injury or Illness, you should not submit a claim under this Plan. The Plan will be entitled to full
reimbursement of Plan payments for medical expenses that are or should have been paid by the third party
coverage. For full details, refer to Section IX - Other Procedures and Provisions under Right of
Subrogation/Reimbursement.
4. Benefits Management Program. Plan benefits could be reduced according to the requirements of the
Benefit Management Program. Refer to Section III - Benefit Management Program.
5. Government Plans. Plan benefits could be reduced or denied if you or your Dependents are entitled to
health benefits under a government program. Refer to Section V Plan Exclusions.
6. Plan Exclusions. Plan benefits could be reduced or denied based on Plan Exclusions. Refer to Section V
Plan Exclusions
Please Note
All claims are subject to a review to decide whether services are covered according to Plan limitations. A
second opinion consultation does not guarantee benefits. For benefit purposes, Westchester Medical Center is
not considered a tertiary facility. You must comply with requests for additional medical documentation as
deemed necessary by the Claims Administrator to evaluate a claim for benefits. Failure to submit requested
documentation or information or to provide a signed release for pertinent medical records could result in
denial of benefits. The Claims Administrator confidentially maintains all medical documents in accordance
with applicable New York State and federal laws. Treatment decisions are independent from payment decisions.
The patient's Physician is responsible for determining whether treatment should be rendered despite whether
the charges are totally or partially included in, or excluded from, coverage under the Plan.
