SSMC Employee Health Benefit Plan
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C. Participating Provider Network Program
The Participating Provider Network program is offered through the PHO Network. These Participating
Providers (Network Providers) have a written agreement with the PHO Network to accept negotiated
allowances as their charges for most Covered Services or Supplies. Participating Providers submit claims
directly to POMCO. Available Plan benefits are paid directly to the Network Provider. The Network
Providers maintain their own professional liability insurance coverage. Each Provider is responsible for the
medical treatment needed or rendered, whether or not the care is covered by the Plan. The PHO Network is
only an administrative body.
Usually, the Network Allowance will be considered the Network Provider's full charge for most Covered
Services or Supplies. Network Providers cannot bill more than the negotiated or scheduled Network Allowance
for Covered Services or Supplies. Covered Services or Supplies for Network Providers are the same as for Out-
of-Network Providers and are subject to the same Plan limitations and exclusions, unless shown otherwise.
You or your Dependents may choose any qualified Health Care Provider for medical care. However, because
the Network Allowances are generally lower than charges by Out-of-Network Providers, choosing Network
Providers results in savings for you and SSMC. See Section I - Summary of Benefits for details.
D. Allowable Fees
Charges that are more than Allowable Fees are not covered. All Plan benefits are based on Allowable Fees for
Covered Services or Supplies. Covered Persons must incur the Services or Supplies while they are eligible and
enrolled in the Plan. Refer to Section I - Summary of Benefits under Allowable Fees for details.
E. Preventive Care
Benefits are available for limited routine screening exams for preventive or well care. Preventive or well care
is routine care unrelated to the diagnosis or treatment of specific symptoms or specific Illness or Injury.
Diagnostic tests and exams related to specific symptoms or treatment of an Illness or Injury are covered
separately under Hospital Expense Benefits and Medical Expense Benefits shown later in this section. If care
or management of an Illness or Injury requiring minimal time or minimal professional expertise is done during
a visit that is primarily for routine preventive or well care, the visit will be considered as routine preventive
care, subject to Plan limitations.
Only the following routine services are covered for Preventive or Well Care Benefits. See Section I -
Summary of Benefits for Plan Copayments and benefit limits.
1. Mammography Screening. Benefits are available for routine mammography screening. Coverage is
limited to the following conditions:
a. Mammography, recommended by Physicians for Covered Persons, at any age, with a personal medical
history of breast cancer, or whose mother or sister has a history of breast cancer;
b. A single baseline mammography for Covered Persons who are 35-39 years of age; or
c. An annual mammography for Covered Persons who are 40 years of age or older.
d. In no event, will the Plan pay more than one routine mammography screening in any 12 consecutive
months.
2. Cervical Cytology/Pap Test. Benefits are available for an annual cervical cytology cancer screening test
including collecting and preparing pap smears, and the laboratory diagnostic service to examine and
evaluate the pap smear. The related cervical exam is not covered. Coverage is limited to once per
Calendar Year for eligible and enrolled females, ages 18 years or older.
3. Well Child Care. Benefits are available for routine well child care given for eligible and enrolled
Dependent children from birth to age 19 (until but not 19th. birthdays) or up to age 23 for full time student.
