SSMC Employee Health Benefit Plan
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following Services or Supplies billed by the Home Health Care Agency:
a. Part-time or intermittent home nursing care by, or under the supervision of, a registered professional
nurse (RN). Full-time care is not covered;
b. Part-time or intermittent home health aide services rendered primarily for the care of the patient. Full-
time care is not covered;
c. Rehabilitative physical, occupational, or speech therapy.
d. Medical Supplies, drugs and medicines that would have been allowed had the patient been confined in
a Hospital or Skilled Nursing Facility;
e. Laboratory services that would have been covered had the patient been confined in a Hospital or
Skilled Nursing Facility;
f. Medical social services; or
g. Nutritional counseling by a licensed dietitian.
The Claims Administrator may periodically review medical records to confirm that home care continues to
meet Plan criteria for benefits. Benefits are not payable for care furnished to anyone other than the covered
patient. These benefits stop when home health care is no longer needed instead of Inpatient Care. Benefits
are not payable for any services rendered to Household Members or relatives, other than the patient for
whom the home health care was approved. Coverage is not provided for any Services or Supplies that were
not included in the approved Home Health Care Plan.
9. Hospice Care Agency. Benefits are available for Hospice care furnished by a Hospice Agency to a
terminally ill Covered Person who has been certified by his or her attending Physician as having a life
expectancy of six months or less. Benefits are available during the period the Covered Person is accepted
by the Hospice into its program. Under this benefit, the patient's medical services must be provided by,
or obtained through, the Hospice care agency.
The Hospice Care Plan must be established and reviewed regularly by the attending Physician and the
appropriate personnel of the Hospice Agency. The Hospice care must be intended to provide palliative and
supportive care to the terminally ill patient and supportive care to their families. A written evaluation must
be prepared by the Hospice coordinator showing the patient's medical and social needs with a plan of care
and services needed to meet those needs. The Hospice Agency must bill all services.
a. Covered Hospice Expenses. Benefits are available for the following Hospice Service or Supplies
when part of an approved Hospice Care Plan.
1) Bed patient either in a designated Hospice Unit or in a regular Hospital bed;
2) Day care service provided by the Hospice Agency;
3) Home care and Outpatient services provided by the Hospice including intermittent part-time
nursing (up to 8 hours per day) by registered nurses, licensed practical nurses or home health aides;
physical, occupational, speech or inhalation therapy; dietary or nutritional counseling;
4) Psychological counseling;
5) Medical social services to include evaluation of the patient's social, emotional, and medical needs,
the home and family situation, identification of community resources available to meet patient's
needs, and assisting the patient or the family to obtain those resources;
6) Laboratory, x-rays, chemotherapy, or radiation therapy when needed to control symptoms;
7) Medical Supplies, prescription drugs and medications considered approved for the patient's
condition. Benefits are not payable if the drugs or medications are considered Experimental;
8) Medical care, consultations, or case management services provided by the Hospice Physician or
other Physician designated by the Hospice to render services; or
9) Periodic respite care.
10) Bereavement Counseling is covered separately. See Bereavement Counseling shown later in this
section.
