SSMC Employee Health Benefit Plan
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Providers licensed to render such care. Care must meet same criteria as Rehabilitative Therapy
shown later in this section under Medical Expense Benefits.
2) Other Outpatient Services and Supplies. Benefits are available for other SNF Outpatient care.
To be eligible for coverage under this title, the medical Service or Supplies must otherwise be
covered under the Plan. Such care 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.
Emergency Medical Care benefits are available if 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.
7. Substance Abuse Facility or Center. Benefits are available for Inpatient and Outpatient expenses
billed by an approved Substance Abuse Facility (freestanding agency or facility, or a Hospital center)
for diagnostic and Rehabilitation care for treatment of alcohol or drug abuse. Services and Supplies
must be provided by the facility and rendered by facility employees. Separate charges billed by other
Providers will not be Covered. See Section X - Definitions under Substance Abuse Facility. You
should obtain pre-approval from the Claims Administrator before treatment begins to be sure that the
facility or center and the proposed care meet Plan requirements. Refer to Section l - Summary of
Benefits under Hospital Expense Benefits for benefit limits that apply to any combination of Inpatient
or Outpatient treatment.
Benefits are not payable for visits that consist primarily of participation in programs of a social,
recreational, or companionship nature. Coverage does not include benefits for partial Hospitalization
or for day or night care centers. Services must be rendered by the facility's employees.
a. Inpatient Substance Abuse Rehabilitation. Coverage for each Covered Person is limited to 30
Inpatient benefit days per Calendar Year for an Approved Plan of Care. Once 30 Inpatient days
are paid for a Covered Person during a Calendar Year, benefits do not become available again until
the next Calendar Year. Private room charges are limited to the Average Semi-private Room
Rates, whatever reason for use. Room and board charges billed for the date of discharge are not
covered. Benefits are not available for partial Hospitalization, day or night care or Custodial care,
residential care, education or training.
b. Outpatient Substance Abuse Rehabilitation. Benefits are available for you or your Eligible
Dependent for an Approved Plan of Care for Outpatient services rendered at a certified Substance
Abuse Facility (freestanding agency or facility or a Hospital center) for diagnosis and treatment of
Substance Abuse (alcohol or drug dependency). Coverage also includes an Approved Plan of
Care for Outpatient services rendered and billed by Certified Substance Abuse Counselors. Each
visit must consist of at least one of the following: individual or group counseling; activity
Rehabilitation therapy; or diagnostic evaluations by a Physician or other licensed professional to
decide the nature and extent of the patient's Illness.
8. Home Health Care Agency. Benefits are available for an Approved Plan of Care for home care services
when rendered and billed by an accredited and certified Home Health Care Agency. The patient's
condition must be such that confinement in a Hospital or a Skilled Nursing Facility would be necessary if
home health care services were not provided. The attending Physician must certify that the patient required
such care instead of Hospitalization.
Each visit by a member of the home care team is considered one visit. Each visit can last up to four hours.
Benefits are limited to 40 home care visits per Calendar Year. Once 40 visits have been paid during a
Calendar Year, coverage is not available for the remainder of that Calendar Year. See Section I -
Summary of Benefits under Hospital Expense Benefits for benefit limits. To be covered, Service or
Supplies must be ordered by the attending Physician, included in the Home Health Care Plan, and furnished
by or coordinated by the Home Health Care Agency. Coverage is limited to Allowable Fees for the
