SSMC Employee Health Benefit Plan
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subluxation of or in the vertebral column. The therapeutic care must be directed at functional improvement
(active treatment). Benefits will not be paid for any Maintenance Care (care to prevent worsening). Office
visits billed on the same day as spinal manipulation will not be covered unless documentation shows the
separate exam was medically indicated. For example: Initial exams to determine treatment plans or
periodic follow-up exams to verify progress. After 15 active treatment visits, continued coverage is subject
to approval by the Claims Administrator. The Claims Administrator will request medical records from the
Provider to confirm treatment is covered in accordance with Plan provisions. If care is no longer
considered active treatment, benefits will not be available for that care.
9. Outpatient Mental Illness Care. Benefits are available for Outpatient treatment of Mental Illness.
Coverage is limited to once per day unless additional visits are found Medically Necessary. Exception:
Coverage will be provided separately for an individual and a group therapy visit given on the same day.
Refer to Section 1 -Summary of Benefits for special limits on Outpatient Mental Illness Care. Services
must be given and billed by a psychiatrist, licensed clinical psychologist, Certified Mental Health Social
Worker or Certified Mental Health Nurse; or billed by a Hospital or mental health facility, Physicians
group or clinic for the services of a psychiatrist, licensed clinical psychologist, Certified Mental Health
Social Worker or Certified Mental Health Nurse. Care or treatment must be directed at a diagnosed Mental
Illness.
Benefits are not payable for care primarily directed at raising the level of consciousness, social
enhancement, retraining, professional training or counseling limited to everyday problems of living,
marriage counseling, family counseling, sex therapy, or support groups. Bereavement Counseling is
covered separately shown later in this section. Under no circumstances are benefits provided for therapy
that includes the satisfaction of requirements for professional training. Alcohol or drug addiction treatment
is not covered under this benefit. See Substance Abuse Facility benefits shown previously in this section.
10. Bereavement Counseling. Benefits are available for bereavement counseling services by Hospice
counselor, pastoral counselor or by qualified Professional Healthcare Providers following the death of you
or your covered Dependent. Counseling must be rendered with six months of the event and is limited to
15 bereavement counseling sessions per event for any combination of family members. Family members
include the deceased Covered Person's parents, parents-in-law, spouse, children, brother, sister or
grandparents. Counseling sessions do not require orders from attending Physician.
11. Diagnostic Tests. Benefits are available for diagnostic X-ray, laboratory, pathology, machine tests and
other diagnostic testing given on an Outpatient basis by covered Professional Healthcare Providers, clinics,
Urgent Care Facilities, Hospitals or other covered facilities, or independent labs. Tests must be required or
ordered due to related symptoms or treatment of an Illness or Injury. Routine screening or preventive tests
are not covered under this benefit. Coverage includes separate Physicians' charges for interpretations of
covered diagnostic tests given by Hospitals or Skilled Nursing Facilities or other covered facilities.
12. Radiation Therapy. Benefits are available for radiation therapy procedures and related Supplies.
Coverage includes use of x-rays, radium and radioactive isotopes to treat an Injury or Illness. Charges for
office visits, consultations and diagnostic x-rays are covered separately. No coverage is provided for high
dose radiation therapy in connection with autologous bone marrow transplant, stem cell rescue agent or
other hematopoietic support procedures that are not covered by the Plan. See Transplants shown later in
this section for details.
13. Chemotherapy. Benefits are available for non-Experimental chemotherapy for Outpatient services given
in a clinic, Professional Healthcare Provider 's office or Outpatient department of a Hospital. Coverage
includes professional chemotherapy services and related Supplies. Home chemotherapy includes
chemotherapy Supplies, non-Experimental drugs and equipment used in the home when home setting is
found medically appropriate according to Plan provisions. Non-Experimental chemotherapy drugs
