SSMC Employee Health Benefit Plan
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of 90 days for each Covered Person's Lifetime for any combination of Mental Illness Inpatient
stays in Hospitals or other covered Inpatient mental health facilities. Once 90 Inpatient benefit
days have been paid, no further Plan payments will be made for Inpatient Mental Illness Care for
the remainder of that person's Lifetime.
6) Substance Abuse Detoxification. Inpatient detoxification is considered a medical condition
eligible for acute care Hospital benefits. However, detoxification coverage is limited to no more
than seven days in a Calendar Year. Expenses for Inpatient Substance Abuse (alcohol or drug
abuse) Rehabilitation are covered separately. See Substance Abuse Facility shown later in this
section.
b. Outpatient Hospital Expenses. Benefits are available for you or your Dependents for Services or
Supplies that are ordered by the attending Physician, found Medically Necessary and require a Hospital
Outpatient setting. Services and Supplies must be provided by the Hospital and rendered by employees
of the Hospital. See Section I - Summary of Benefits for special limits. Separate charges for services
by a non-employee Professional Healthcare Provider are considered separate from this benefit.
Benefits are available for the following Hospital Outpatient care:
1) Pre-admission Testing. Benefits are available for pre-admission testing done by the admitting
Hospital before Surgery. Separate charges for use of Hospital emergency rooms or Outpatient
rooms are not covered under this benefit. Coverage is not provided for repeat pre-admission
testing unless the prior planned admission or Surgery is deferred solely due to a change in the
Covered Person's health. Pre-admission testing will be considered for benefits when all of the
following requirements are met:
a) The tests are ordered by a Physician as a preliminary requirement before Covered Person's
admission as a registered bed patient for Surgery in the same Hospital;
b) Tests must be consistent with the diagnosis and treatment of the surgical condition.
c) The reservation for a Hospital bed and operating room is made before testing was done;
d) The patient must be physically present at the Hospital for needed tests; and
e) Surgery must take place within seven days after the tests are given.
2) Emergency Room Care. Coverage includes use of the Hospital emergency or Outpatient room
and related Hospital Service or Supplies for necessary treatment. Plan Benefits are based on
whether care is considered Emergency Medical Care or non-emergency care. See Section I -
Summary of Benefits under Hospital Expense Benefits for details.
a) Emergency Medical Care. To be considered Emergency Medical Care, care must be
rendered as follows:
(1) Serious Accidental Injury. If initial emergency room treatment of an Accidental Injury is
rendered within 72 hours of the accident, Outpatient Hospital services up 90 days
following the accident will be considered Emergency Medical Care.
(2) Sudden and Serious Illness. Initial treatment of a sudden and serious or acute conditions
rendered to a Covered Person whose condition requires immediate medical care. This
initial treatment must be rendered within 12 hours from the onset of serious or acute
symptoms. The Illness or condition must be diagnosed by the attending Physician and
found so serious or acute that the condition could impose a threat to the person's life or
bodily function if immediate medical care not given. Examples of sudden and serious
Illness or acute conditions that may qualify for this benefit include, but are not limited to,
acute appendicitis attack, acute asthma attack, stroke, convulsions, coma, fainting,
hysteria, overdoses, food poisoning, shock, acute coronary pain, possible or actual heart
attack, severe hemorrhage, severe nosebleed, acute abdominal pain, frostbite or foreign
body in eye, ear, nose or throat.
