SSMC Employee Health Benefit Plan
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b. Expenses not Covered. Benefits are not payable for any of the following services:
1) Financial or legal counseling or funeral services and arrangements;
2) Homemaker or caretaker services that are not solely related to the medical care of the patient. This
includes a sitter or companion for any family member, house-cleaning, house maintenance,
transportation or any other service supplied to family members except bereavement counseling.
3) Services or Supplies Incurred during a period of Hospice acceptance that are not provided by or
approved by the Hospice Agency.
4) Services or Supplies rendered by volunteers or others who do not regularly charge for their services.
Services rendered by Immediate Relatives or Household Members.
G. Medical Expense Benefits
(Other Providers Medical/Surgical Services and Supplies)
Coverage is available for expenses Incurred for the following services rendered for you or your Dependents. To
be covered, services must be rendered or ordered by the attending Physician and found Medically Necessary,
according to Plan limitations. Be sure to read this section carefully. Some care or treatment, Services or
Supplies are shown separately and are subject to different limitations. Covered Services or Supplies must be
rendered and billed by Covered Professional Healthcare Providers. Refer to Section I - Summary of Benefits
for benefit limits.
1. Surgical Care Expenses (Inpatient and Outpatient). Benefits are available for surgical procedures
performed on an Inpatient or Outpatient basis. Charges by the surgeon, assistant surgeon, and the
anesthesiologist are covered separately from facility expenses.
a. Surgeon Expenses. Benefits are available for covered surgical procedures rendered by a qualified
medical Doctor or osteopath, a podiatrist for covered foot Surgery, a dentist for covered oral
procedures or other qualified Professional Healthcare Provider whether done at a Hospital, clinic,
office, or other location. If done in the Doctor's office, separate charges for surgical trays will be
considered. To determine the Allowable Fees for multiple surgical procedures performed during the
same operative session, the following general rules are used:
1) Through the same incision, natural body orifice, or operative field. The charges for each
procedure will be considered one charge. Then, the allowable fee eligible for consideration will be
based on the UCR or Network Allowance for the major procedure.
2) Through different incisions, natural body orifice or operative fields. The Allowable Fees will be
based on the UCR or Network Allowance for the first procedure, then each additional procedure
could be allowed at a reduced allowance, usually 50% of the UCR or Network allowance for the
additional procedures.
3) The allowable fee determination will also take into account operations that involve co-surgeons or
team surgeons when found Medically Necessary to perform complex multiple procedures.
The surgical allowance includes the usual care given by the surgeon before and after Surgery. Separate
charges by the surgeon (or by another Provider substituting for the surgeon) for related care after
Surgery (postoperative care) will not be paid.
b. Maternity. Benefits are available for services by a qualified Physician, or certified nurse midwife, for
childbirth, cesarean section, and other maternity related surgical procedures, given for you or your
Spouse. The Plan excludes Services or Supplies related to surrogate maternity care and maternity care
for Dependent Children. The payment for childbirth or termination of a Pregnancy will include the
usual care given by a Provider before and after delivery, miscarriage, abortion, cesarean section or
