SSMC Employee Health Benefit Plan
43
other termination of Pregnancy. Separate charges by the obstetrician or surgeon for prenatal or
postnatal care will not be covered.
c. Assistant Surgery. Benefits are available for an assistant surgeon when found Medically Necessary
for a covered surgical procedure. The surgical procedure must be done in a Hospital or other covered
facility where there is no qualified staff available to assist the surgeon. A Hospital or other facility
regulation, in itself, does not establish Medical Necessity. The assistance must be given and billed by
another surgeon or by a medical Doctor, osteopath, podiatrist or dentist qualified to assist during the
covered Surgery. The benefit for the assistant surgeon will be based on 20% of the applicable surgical
allowance. Under no circumstances, will Plan benefits be paid for standby services.
2. Anesthesia. Benefits are available for administration of general anesthesia when found Medically
Necessary for covered surgical procedures. Coverage is limited to administration of anesthesia by
anesthesiologists or administration by Certified Nurse Anesthetists who have contracted with an eligible
Hospital or those under the direct supervision of the operating surgeon and the indirect supervision of an
anesthesiologist. Coverage is also available for acupuncture by a Certified Acupuncturist when rendered
in lieu of general anesthesia. The Plan will not pay benefits for administration of anesthesia by the
surgeon, the assistant surgeon, or by a Hospital employee. The allowance for anesthesia includes the usual
patient consultation before anesthesia and the usual care after Surgery. The Plan will not pay separate
charges for this usual care before and after Surgery. Coverage is also available for administration of
general anesthesia for non-surgical procedures when found Medically Necessary according to Plan
provisions. Under no circumstances, will Plan benefits be paid for standby Services.
3. Second Surgical Opinion Consultation. Benefits are available for patient requested second opinion
consultations before proceeding with a covered surgical procedure. A board-certified specialist whose
specialty is appropriate to consider the need for the proposed Surgery must give the second opinion
consultation. If the consulting specialist renders the Surgery, consultation benefits are not payable. If the
consultant is part of the same Physician or specialty group of the same Physician who first recommended
the surgical procedure(s), consultation benefits are not payable. If the Covered Person seeks a third
opinion, benefits will be provided on the same basis as the second opinion. Whether or not the second (or
third) opinion agrees that Surgery is necessary, the Plan will cover the second opinion consultation. It is the
patient's decision whether to have the Surgery.
4. Inpatient Physician Services
a. Medical/Surgical Care. Benefits are available for Inpatient evaluation and management or
therapeutic services rendered by Physicians during a covered Inpatient stay in a Hospital or other
Inpatient facility. This benefit does not include surgeon, assistant surgeon, anesthesiologist or
obstetrical postoperative care. If in a Skilled Nursing Facility, coverage is provided only for days
approved for room and board. Benefits are not payable for any inpatient days found to be for
Custodial or long-term care. Treatment or care for Inpatient Substance Abuse Rehabilitation is not
covered under this benefit. See separate limitations for Inpatient Mental Illness Care shown below.
Treatment or care for Inpatient Substance Abuse Rehabilitation is not covered under this benefit. See
Substance Abuse Facility shown previously in this section.
If a Covered Person receives care from two or more Providers, benefits may be considered when each
Provider gives treatment for separate and different conditions. Care for more than one visit per day for
each Physician may be considered if found Medically Necessary for the patient's condition, according
to Plan provisions.
b. Mental Illness Care. Benefits are available for Inpatient visits or therapy for Mental Illness, only to
the extent Hospital room and board days were approved. Coverage is limited to one visit per day up to
30 benefit days per Calendar Year for each Covered Person with maximum of 90 benefit days for each
Covered Person's Lifetime.
