SSMC Employee Health Benefit Plan
38
3) Surgery. Coverage includes use of the emergency room, Outpatient room or ambulatory surgery
room and necessary Services or Supplies rendered during the covered surgical procedure,
including recovery. This includes surgical procedures, maternity deliv ery procedures, or setting of
fractures or dislocations. Follow-up care is considered non-emergency care and is covered under
emergency room care shown above. If emergency surgical care meets the same circumstances and
limitations for Emergency Medical Care shown above, benefits will be available as Emergency
Medical Care.
4) Rehabilitative Therapy. Benefits are available for physical therapy, speech therapy and
inhalation/ respiration therapy rendered to improve function lost due to an Illness or Injury. Such
care must be ordered by the attending Physician and rendered by qualified therapists licensed to
render such care. Care must meet same criteria as Rehabilitative Therapy shown later in this
section under Medical Expense Benefits. Separate charges for use of Hospital emergency or
Outpatient rooms are not covered under this benefit.
5) Other Outpatient Hospital Services and Supplies. Benefits are available for other Hospital
Service or Supplies when ordered by the attending Physician and found Medically Necessary. To
be eligible for this benefit, the medical care must otherwise be covered under the Plan. Such
services will be subject to the same criteria and limitations applied to the same type of services
covered under Medical Expense Benefits shown later in this section. Separate charges for use of
Hospital emergency or Outpatient rooms are not covered under this benefit. Other services
include, but are not limited to:
a) Diagnostic tests including x-rays, lab, pathology and machine tests;
b) Radiation or x-ray therapy for non-Experimental treatment of an Illness or Injury;
c) Kidney dialysis;
d) Chemotherapy for non-Experimental treatment of an Illness or Injury; or
e) Clinic Service or Supplies.
Please Note
No coverage is provided for high dose radiation therapy or high dose chemotherapy in connection with a
autologous bone marrow transplantation that is not covered by the Plan. See Transplants shown later in this
section for details.
A person receiving kidney dialysis could be eligible for Medicare due to End Stage Renal Disease (ESRD). Refer
to Section VI - Medicare Integration with Plan Benefits.
2. Birth Center. Benefits are available for maternity care by a Birth Center to the extent such expenses
would have been allowed if provided by a Hospital. Coverage includes services by midwives and Routine
Newborn Nursery Care.
3. Mental Health or Psychiatric Facility. Coverage is available for Inpatient Mental Illness Care rendered
by a Private Psychiatric Facility, a Public Psychiatric Facility (government owned) or by a Residential
Psychiatric Treatment Facility on the same basis as Hospital expenses shown previously in this section.
Coverage is limited to 30 benefit days per Calendar Year for each Covered Person with a maximum of 90
benefit days per Covered Person's Lifetime for any combination of Inpatient Psychiatric Facilities or
Hospital stays for Mental Illness Care. Private room charges are limited to Average Semi-private Room
Rates, whatever reason for use. Room and Board charges for the date of discharge are not covered.
4. Ambulatory Surgical Facility. Coverage includes all necessary Service or Supplies rendered by the
facility on the day of the covered Surgery and within 48 hours following the Surgery. Coverage is limited
to procedures that cannot be safely done in a Physician's office due to complexity of procedure or the
patient's condition or when rendered for Emergency Medical Care. Benefits will be available as Emergency
Medical Care when care meets the same circumstances and limitations for Outpatient Hospital Expenses,
Emergency Medical Care shown previously in this section. See Section 1 - Summary of Benefits under
Hospital Expense Benefits.
