SSMC Employee Health Benefit Plan
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5. Specialist Consultations. Benefits are available for consultation services in a Hospital, or Skilled Nursing
Facility, clin ic or the consultant's office. A consultation is an examination requested by an attending
Physician to obtain an opinion in the evaluation and management of an Illness or Injury. When the
attending Physician requests a specialist's opinion, benefits may be provided for as many opinion
consultations as necessary. However, if the consultant takes over the management (treatment) of the
condition, subsequent management visits are not considered consultations. When the attending Physician
refers a patient to a specialist or other Physician for the management (treatment) of an Illness or Injury, the
visits are not considered consultations. Benefits are not payable for consultation expenses when the
consultant is part of the specialty group or surgical group office as the requesting Physician.
6. Physician Outpatient Services. Benefits are available for Outpatient evaluation and management or
therapeutic medical care rendered and billed by Physicians, clinics or medical groups. Coverage includes
Physicians or qualified Professional Healthcare Providers employed by Physicians, clinics or medical
groups and rendering a covered medical service within the scope of their license. Outpatient care means
care given in the Outpatient or emergency room of a Hospital, Provider's office, clinic, or elsewhere on
other than an Inpatient basis. However, Plan excludes home visits unless covered under the Home Health
Care Agency and Hospice benefit. Consultations, Surgery and obstetrical procedures are covered
separately.
Outpatient Mental Illness Care, chiropractic care, podiatrist care or foot care, Rehabilitation, and other
services are considered separately as described later in this section. Outpatient and Inpatient Substance
Abuse care is covered separately under Substance Abuse Facility shown previously in section.
7. Foot Care and Podiatry Services. Benefits are available for Services or Supplies related to treatment of
the feet. Coverage includes Services or Supplies given by licensed Physicians (medical Doctors,
osteopaths or podiatrists) for conditions of the feet.
a. Medical/Surgical Care. Coverage for foot care is provided on the same basis as care for other
Illnesses or Injuries. However, Services or Supplies for routine foot care are not covered. Exception:
Benefits may be considered for related routine foot care recommended by an attending Doctor (M.D. or
D.O.) treating a patient for metabolic disorders (such as insulin-dependent diabetes) and peripheral
vascular disease. See Section V - Plan Exclusions for details on foot care not covered by the Plan.
b. Foot Appliances. Foot Orthotics, orthopedic shoes and other supportive devices of the foot are
covered on a limited basis for certain conditions when not needed primarily for treatment of weak,
strained, flat, unstable or unbalanced feet. Generally, the Plan covers Orthotics, orthopedic shoes and
other supportive appliances for the feet that are custom-made appliances ordered by a Physician to
control change in the shape of the foot during growth or take pressure off injured or inflamed parts of
the foot, or following covered Surgery. For example: conditions such as calcaneal bone spur, clubfoot,
hallux valgus, metatarsal bursitis, morton's neuroma, nerve Injury, osteoarthritis would be considered
for benefit determination. Foot appliances would not be allowable for conditions such as; flatfeet,
internal derangement of the knee, leg length inequality, lumbar and/or pelvic instability/dysfunction,
tibial tendonitis. A predetermination of coverage is suggested to avoid any misunderstanding of
allowable services.
Duplicate appliances are not covered. Replacement of a covered foot appliance is allowable only when
needed due to growth or due to change in patient's condition which makes the previous Orthotic no
longer serviceable.
8. Spinal Manipulation/Chiropractic Services. Benefits are available for spinal manipulation care given by
a licensed chiropractor or other Professional Healthcare Provider. Spinal manipulation is skeletal
adjustments, or other treatment for the detection or correction of the structural imbalance or subluxation in
the human body to remove nerve interference resulting from, or related to distortion, misalignment or
