SSMC Employee Health Benefit Plan
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purchased at a Pharmacy are considered under Prescription Expense Benefits shown later in this section.
No coverage is provided for high dose chemotherapy 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.
14. Rehabilitation Therapy. Benefits are available for Outpatient Rehabilitation therapy. Therapy that is part
of an Approved Plan of Care for Home Health Care Agency or Hospice Agency is considered separately.
Coverage is limited to the following:
a. Physical Therapy. Benefits are available for short-term physiotherapy of the type and duration
prescribed by the attending Physician and rendered by a licensed physical therapist. Therapy must be
needed to significantly and measurably restore body function lost due to an Illness or Injury. If the
Covered Person, reaches maximum potential for significant and measurable improved function, or if
care is found by the Claims Administrator to be Maintenance Care, benefits will no longer be payable.
If care is given beyond the type or duration ordered by the attending Physician, benefits will not be
payable for that care. Massage, exercise programs, and separate charges for use of exercise equipment
are not covered. Long-term care is not covered.
Physical therapy is covered, for example, when body function is lost due to conditions such as
Accidental Injury, cerebrovascular accident, stroke or acute stages of arthritis. Physical therapy is
not covered, for example, when physical dysfunction is due to conditions such as mental retardation,
spina bifida, developmental delay, autism, educational or occupational deficits, or syndromes
associated with perceptual and conceptual dysfunction.
b. Speech Therapy. Benefits are available for an approved plan of short-term speech therapy. The
therapy must be ordered by the attending Physician and needed to restore speech function lost due to
Illness or Injury or to improve speech function following Surgery for correction of a birth defect that
caused the speech dysfunction. The therapy must be rendered by a qualified licensed speech
therapist. Speech therapy must be directed at significant and measurable restoration and
improvement of speech function. Speech function is the ability to express thoughts, speak words
and form sentences. If the maximum potential for improved or age appropriate function is reached,
benefits will no longer be payable. Speech therapy is not covered for conditions such as stammering,
stuttering, lisping, articulation disorders, changing an accent, dyslexia, abnormal speech
development, hearing loss that is not medically documented, or similar disorders. Benefits are not
payable for myofunctional or tongue thrust therapy. Speech dysfunction due to congenital anomalies,
brain dysfunction, or developmental delays will not be paid.
Speech therapy is covered, for example, when speech function is lost due to conditions such as
cerebrovascular accident, craniotomy, head Injury, meningitis, congenital anomalies corrected by
Surgery (such as cleft lip or cleft palate), vocal cord nodules, or Surgery. Speech dysfunction due to
medically documented chronic otitis media or middle ear infections, during the formative years of
speech, that cause a delay in either speech or language (non-acute, non-recurrent otitis media does not
meet these criteria) would be covered. Speech therapy is not covered, for example, when speech
dysfunction is due to conditions such as environment, psychosocial delays, mental retardation, spina
bifida, autism, educational or occupational deficits, cerebral palsy, syndromes associated with
perceptual and conceptual dysfunction, dyslexia, or attention deficit disorders.
c. Inhalation Therapy. Benefits are available for short-term Outpatient inhalation therapy given for you
or your Dependents when ordered by the attending Physician. Charges must be billed by a Hospital,
SNF, clinic, or by a Physician for restoration therapy services given by certified licensed respiratory
therapists, Registered Nurses, or Physicians. Custodial or Maintenance Care is not covered.
d. Occupational Therapy. Benefits are available for short-term occupational therapy of the type and
duration prescribed by the attending Physician and rendered by licensed occupational therapist.
