SSMC Employee Health Benefit Plan
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intensive care units, cardiac care unit or similar rooms. Coverage for private room charges will be
limited to the Average Semi-Private Room Rates, whatever reason for use. You will be
responsible for payment of charges that are more than the Hospital Average Semi-Private Room
Rates. Room and board charges for the date of discharge are not covered.
2) Hospital Miscellaneous or Ancillary. Services or Supplies received while the patient is eligible
for the above room and board benefits may be allowed when ordered by the attending Physician
and found Medically Necessary for treatment of Illness or Injury. This includes, but is not limited
to, drugs and medicines; biologicals, sera, intravenous preparations, lab and pathology tests; use of
operating room, delivery room or other treatment room and related Supplies; administration of
anesthesia, agents and related Supplies; use of physical or occupational therapy equipment and
related Supplies; oxygen and related Supplies; administration and processing of blood but not
including charges for blood and plasma; use of x-ray and radiation therapy equipment including
Supplies, visualizing dyes, radioactive or nuclear materials; use of equipment, drugs and related
Supplies for non-Experimental chemotherapy: use of dialysis equipment and related Supplies.
Coverage is not provided for personal expenses including, but not limited to, television, barber,
telephone and clothing.
Please Note
Inpatient private duty nursing expenses are covered separately. See Professional Nursing shown later in this
section. Separate professional charges for interpretation of Hospital testing and other medical services are
not considered Hospital expenses. These charges are considered Physician charges and are considered
separately from Inpatient Hospital expenses. Charges for take home Supplies, equipment or drugs are not
considered Inpatient expenses and are considered for benefits separately from Inpatient Hospital expenses.
3) Medical/Surgical Conditions are covered for unlimited days based on Medical Necessity for
acute Inpatient Care. See Section I - Summary of Benefits for benefit limits. See separate
coverage limits for Mental Illness Care and Substance Abuse care shown below.
4) Maternity/Nursery Care. Pregnancy or maternity care is covered the same as any other Illness
for you or your Spouse including but not limited to, care related to Pregnancy complications,
normal delivery, cesarean section, miscarriage and elective abortions. However, the Plan excludes
expenses related to surrogate maternity care and maternity care for Dependent Children.
Benefits are available for your newborn child from the moment of birth when enrolled in your
family coverage within 31 days after the date of birth. Benefits will be available for unlimited
Inpatient days if he/she is sick, injured, premature or born with congenital defects and requires
medical care above that needed for routine nursery care. However, coverage for Hospit al Service
or Supplies considered primarily Routine Newborn Nursery Care is limited to four days. After
four days, continued care must be approved due to a medical condition of the Newborn that
required continued Inpatient treatment. Extended Inpatient days primarily due to the mother's
continued stay are not covered even if the mother is providing personal care such as breastfeeding.
Newborn care includes Services or Supplies related to routine circumcision.
According to the Newborns' & Mothers' Health Protection Act, a federal law, a health plan or its
managed care program, that offers coverage for Hospital stays in connection with childbirth cannot
limit that coverage to less than a 48-hour Hospital stay following an uncomplicated normal
delivery; or less than a 96-hour Hospital stay following a cesarean section delivery. In addition,
the health plan cannot restrict benefits for any portion of the required minimum stays in a way that
is less favorable than the benefits provided for any preceding portion of the stay.
5) Mental Illness or Psychiatric care for treatment of diagnosed Mental Illness is only allowed when
the patient requires such care for the protection of himself or others or when the course of
treatment can only be carried out on an Inpatient basis. Benefits are available for Covered
Inpatient stays up to 30 benefit days per Calendar Year for each Covered Person with a maximum
