SSMC Employee Health Benefit Plan
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SECTION IV - COVERED SERVICES
Be sure to read this entire document for details on Plan benefits, Deductibles, Percentage Copayments, benefit
limits, Covered Services or Supplies, exclusions and other limitations. The listing of expenses shown in this
section does not guarantee benefits. All listed Services or Supplies are subject to Plan limitations and
exclusions. The extent of your coverage is based on the Plan benefit schedule for which you are eligible. See
Section V - Plan Exclusions for applicable exclusions, Section X - Definitions for details on terms that may
apply to Covered Services or Supplies and Section I - Summary of Benefits for details on the Plan benefit
schedules and limits.
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. 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.
A. Plan Benefit Schedules
Plan coverage and benefits are based on two benefit schedules, Schedule A Benefits and Schedule B Benefits.
Refer to Section II - Eligibility and Enrollment details on the eligibility requirements for each schedule.
Your coverage is based on the Plan benefit schedule for which you are eligible.
1. Schedule A Benefits. Coverage for eligible Full-time Employees and their eligible Dependents include
Preventive Care Expense Benefits, Hospital Expense Benefits, Medical Expense Benefits and Prescription
Drug Benefits. Coverage for eligible Part-time Employees who work 30 but less 37.50 and their
Dependents includes the same coverage, except Prescription Drug Expenses do not become available until
after five full years of eligible employment. For eligible part-time Employees who work 22.50 but less
than 30 hours per week, only Preventive Care Benefits, Hospital Expense Benefits and Medical Expense
Benefits coverage is available and Dependents are not eligible until after five full years of employment.
2. Schedule B Benefits. Full Plan coverage is not available and Dependents are not covered under this
Schedule. Limited coverage is available for eligible part-time Employees working 18 hours but less than
22.50 hours per week. Coverage is available only for SSMC Inpatient Care, limited SSMC Outpatient care
and ambulance to or from SSMC. See Section 1-Summary of Benefits under Schedule B Benefits.
B. Professional Healthcare Providers
Unless shown otherwise, Professional Healthcare Providers must give services and/or services must be ordered
by a Professional Healthcare Provider licensed to order such care. A Professional Healthcare Provider is a
person who is licensed under New York State Law to render or prescribe covered medical services and is
operating within the restrictions or scope of that license. Sometimes, this may require that the Covered
Services or Supplies be ordered by a Professional Healthcare Provider who is licensed to evaluate, manage and
prescribe medical treatment for the medical condition. Outside New York State, licensed Professional
Healthcare Providers will be covered to the extent that they would have otherwise been covered if operating in
New York State. Then, the Provider must be licensed in the state of jurisdiction and giving a service within the
restrictions of that license.
