SSMC Employee Health Benefit Plan
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Children age 19 (up to 23 for full-time student) or older are not eligible for these benefits. Coverage is
intended to be consistent with the clinical standards established by the American Academy of Pediatrics or
standards established by the New York State Department of Health. If these standards change, the Plan
will automatically cover the new recommended standards. New immunizations will be automatically
covered as designated by the New York State Department of Health or the New York Superintendent of
Insurance.
a. Routine Physician Nursery Care. Covers the initial newborn examination or nursery visits for the
first four days of Inpatient routine nursery care. Coverage includes routine circumcision. Inpatient
Physician care after four days will be excluded unless the baby requires care due Illness or Injury or
requires special care due to premature birth. Then, Medical Expense Benefits shown later in this
section become available. If the baby's routine care is extended due to the mother's continued stay,
benefits will not be paid even if the mother was needed to provide basic care, such as breastfeeding.
Separate charges for routine newborn care billed by an anesthesiologist or the delivering Physician are
not covered.
b. Routine Well Child Care/Immunizations. Coverage is limited to the following routine child care
services for Dependent children from birth to age 19 (up to age 23 for full-time student) when given by
qualified Professional Healthcare Providers:
1) Medical History
2) Usual routine well child physical exams including screening tests for hearing and vision and
routine circumcision.
3) Usual routine preventive lab tests, screening for tuberculosis and anemia.
4) General developmental assessments and anticipatory guidance.
5) Age appropriate immunizations based on the current schedule for immunizations or guidelines
recommended or mandated by the New York State Department of Health or the American
Academy of Pediatrics. Currently coverage includes diphtheria, tetanus, pertussis, polio, measles,
mumps, rubella, hepatitis b, hemophilia influenza type b., varicella (chickenpox), and
pneumococcal immunizations. Other immunizations will become covered as designated by the
New York State Department of Health or the American Academy of Pediatrics. Immunizations
given later than the age level recommended for the immunization will be covered if medically
appropriate for the child's age and administered to the child before age 19 (up to age 23 for full
time student).
6) Well child care coverage is available for usual visit frequency as follows:
a) At birth for newborn routine nursery care.
b) Every two months from birth to six months.
c) Every three months from nine to 18 months.
d) Every year from ages two to six years.
e) Every two years for ages seven to 19 (up to age 23 for full-time student).
F. Hospital Expense Benefits (Hospitals and other Facilities)
1. Hospital. Benefits are available for Inpatient and Outpatient care billed by a Hospital. Services or
Supplies must be furnished by the Hospital and given by its employees. Separate charges for
professional services of employees are not covered. See Section I - Summary of Benefits for limits.
Services billed by non-employee Physician or other Professional Healthcare Providers are covered
separately. Benefits are available for the following Service or Supplies:
a. Inpatient Hospital Expenses. Medical Service or Supplies received by a Covered Person during an
Inpatient stay when ordered by the attending Physician and found Medically Necessary for short-term
acute care of Illness or Injury.
1) Room and Board, including general nursing, in rooms of two or more beds, semi-private,
