SSMC Employee Health Benefit Plan
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e) Pre-adoptive Newborn from the moment of birth under a family Plan when all of the following
conditions are met:
(1) You enroll the child, you intend to adopt, in your family coverage within 31 days of the
birth; and family coverage Participation Payment, if any, is made;
(2) You take physical custody of the child upon discharge from the Hospital or Birth Center;
and
(3) Within 31 days of the child's birth, you file a petition to adopt or for temporary legal
guardianship under New York State Domestic Relations Law.
Coverage will not be provided for initial Inpatient treatment of a pre-adoptive Newborn, if the
child's biological parent has health coverage for that care. Also, if a notice of revocation of
the adoption has been filed, or a biological parent revokes consent to the adoption, coverage
will not be provided. If Plan benefits were paid for pre-adoptive Newborn, whose adoption
was revoked, you may be requested to reimburse the Plan in the amount of those payments.
Coverage is not provided for any expenses Incurred by the natural mother or any medical care
or treatment of the Newborn before actual physical birth.
Please Note
The residence and support rules are waived if you are required to provide health coverage due to a court
order or divorce decree or q ualified medical support order for a child who is under age 19 and not living in
your home and/or not dependent for more than 50% of his or her support.
To obtain Plan coverage for children you may be required by the SSMC Human Resources Department to
document appropriate certification of guardianship, pre-adoptive status and/or that the child resides in your
home and is dependent on you for support and maintenance. After initial enrollment, the SSMC Human
Resources Department may require periodic proof to verify that Plan eligibility requirements continue to be
met. Failure to provide the required information, when requested, will result in that child being removed
from enrollment and eligibility until proof is provided which supports Plan enrollment. This could cause a
lapse in coverage and/or loss of benefits.
2) Age Requirements. Eligibility is limited to your Dependent children who meet the above child
definition and who are:
a) Under 19 years of age. Your Newborn child is eligible as a Dependent from the moment of
birth. Dependent child remains eligible until the end of the Calendar Year in which he or she
turns age 19;
b) Over 19 years of age, but under 23, who receive more than half their support from you or your
Spouse, and are full-time students (12 or more credit hours) at an accredited secondary school,
College, or University. The full-time student remains eligible until the end of the Calendar
Year in which he/she graduates but no later than the end of the Calendar Year in which he/she
turns age 23.
In the event a Dependent child, between ages 19 and 23 who is a full-time student, is disabled
and is granted a medical leave by the school, he or she is attending, eligibility will continue for
a maximum of 12 calendar months following the month in which the child withdraws from
school, but no later than the end of the Calendar Year in which he/she turns age 23. If the end
of the 12 calendar months occurs during a vacation period, benefits will be extended to the
beginning of the next regular semester.
Your unmarried child, between the ages of 19 and 23, who previously was not eligible for
benefits, or had benefits ended, and returns to a full-time student status, may be reinstated to
family coverage effective the actual date the student commenced full-time attendance at the
high school or an accredited institute of higher learning; or.
