SSMC Employee Health Benefit Plan
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Therapy must be rendered to restore skills lost due to Illness or Injury that are needed to perform every
day tasks. Coverage does not include care directed at employment or educational deficits. Benefits are
not provided for occupational therapy for dysfunctions due to conditions such as mental retardation,
spina bifida, developmental delay, autism, or perceptual and conceptual dysfunction.
15. Kidney Dialysis. Benefits are available for Services, drugs, and Supplies related to kidney dialysis
procedures given and billed by Physicians, or Hospitals, or Medicare certified dialysis centers. Home self-
dialysis is also covered. If on home dialysis, coverage includes related laboratory tests and consumable or
disposable Supplies needed for the dialysis. Coverage also includes Durable Medical Equipment when
found Medically Necessary by the Claims Administrator. Benefits are not available for expenses such as
alterations to the home, installation of electrical power, water supply, sanitation waste disposal, or for air
conditioning, convenience and comfort items.
Please Note
A person receiving kidney dialysis could be eligible for Medicare due to End Stage Renal Disease (ESRD). See
Section VI - Medicare Integration with Plan Benefits.
16. Durable Medical Equipment (DME) . Benefits are available for the rental or purchase, if appropriate, of
DME when ordered by a qualified Physician and found Medically Necessary. The equipment must
customarily be used for therapeutic reasons and suitable for home use. The purchase of equipment is
covered only when it cannot be rented, or when the duration that the DME is needed makes the purchase
less expensive than rental. Coverage will be provided based on medical documentation and Plan
limitations in effect at the time the DME is purchased.
Coverage includes the necessary Supplies to operate the equipment. Duplicate equipment is not covered,
whatever the reason. The replacement of purchased DME may be covered only when the existing
equipment is no longer serviceable due to change in body condition, or is no longer repairable. DME
replacement due to loss, theft, or destruction is excluded. The necessary repairs and maintenance of
purchased equipment may be allowed, unless covered by a warranty or purchase agreement. Charges for
delivery and service are not covered.
Examples of covered DME are standard Hospital beds, respirators, canes, crutches, walkers, and
wheelchairs. Such equipment, for example, does not include hearing aids, eyeglasses, contact lenses, blood
pressure monitors, thermometers, shoes or other articles of clothing, communication devices, computers, air
conditioners or purifiers, humidifiers, comfort it ems or convenience items. For additional limitations on
this service, see Section X - Definitions under Durable Medical Equipment.
17. Ambulance. Coverage includes professional or volunteer land ambulance transportation. Air or sea
ambulance is covered only when the patient's condition was so serious that the patient could not be
transported safely by land ambulance or if the location, from which the patient required emergency
transportation, was inaccessible by land ambulance. Transportation must be provided by a Hospital-owned
or professional ambulance or by a certified volunteer ambulance that normally bills for its services.
Coverage is limited to ambulance transportation services to the nearest Hospital or Urgent Care Facility
equipped to handle medical care. Transfer from a Hospital or Emergency Care Center to another Hospital
or other Inpatient facility will be considered when the transfer is necessary because the first facility could
not provide the necessary care and the patient required ambulance transportation to the nearest Hospital or
other Inpatient facility that can provide the needed care.
Benefits are not payable if the patient could have been safely transported by any other means of
transportation. No other types of transportation or travel are covered, whatever the reason. Coverage is not
provided for travel or transportation of persons other than the patient, such as medical personnel, family or
friends, whatever the reason.
