SSMC Employee Health Benefit Plan
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5. Urgent Care Facility Emergency Center. Coverage is available for Service or Supplies rendered and
billed by an Emergency Center or Urgent Care Facility when found Medically Necessary for treatment of
an Illness or Injury. Coverage includes all necessary Supplies used during the covered treatment. To be
eligible for this benefit, medical Service or Supplies 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. 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.
6. Skilled Nursing Facility /Convalescent Facility/Rehabilitation Facility (SNF)
a. Inpatient SNF Services. Benefits are available for Inpatient stays in Skilled Nursing Facility,
convalescent facility and Rehabilitation Facility (facilities shown collectively hereafter as SNF) that
meet all of the following criteria:
1) SNF admission must be ordered by the attending Physician and the patient must remain under the
care of a Physic ian during the SNF confinement.
2) SNF stay must begin within 14 days after discharge from acute care Hospitalization of three or
more days (This rule does not apply if the Benefit Management Nurse recommends the SNF stay
instead of Hospitalization.)
3) Care must be for the same Illness or Injury for which patient was Hospitalized;
4) Care must be found Medically Necessary and at a skilled level of care, according to Plan
provisions. Skilled level of care is care of an acute nature that must be furnished by skilled
personnel (qualified technical or professional health personnel) on a daily basis. In no event are
benefits provided for Custodial, Maintenance, long term, nursing home or residential care;
5) Coverage may only be provided for as long as Hospit alization would have been necessary if care in
a Skilled Nursing Facility were not provided; or when Rehabilitation care is so intense it requires
an Inpatient stay; and
6) Diagnostic and therapeutic services must be provided and billed by the facility and rendered by
employees of the facility.
7) Covered Services include the following:
a) Room and board charges, including general nursing care. Private room charges will be limited
to Average Semi-private Room Rates, whatever reason for use. You will be responsible for
the payment of charges over the facility's Average Semi-private Room Rates. Room and board
charges billed on the date of discharge are not covered;
b) Rehabilitative physical, occupational, speech, or inhalation therapies;
c) Medical social services;
d) Ancillary or miscellaneous Service or Supplies, appliances, or equipment that are ordinarily
provided by the facility for its patients, furnished for use in the facility, and would be covered
if the patient was an Inpatient in a Hospital.
Obstetrical conditions or psychiatric conditions do not qualify for this benefit. Benefits are not payable
for any period that care is found to be Custodial, or Maintenance Care, according to Plan provisions.
Separate charges for Inpatient private duty nursing are excluded, whatever the reason for use. Take
home Supplies or drugs are not covered under this benefit. Personal services such as telephone, TV,
barber, etc. are not considered medical expenses and will not be paid.
b. Outpatient SNF Services.
1) Rehabilitative Therapy. Benefits are available for Outpatient 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 Professional Healthcare
