SSMC Employee Health Benefit Plan
50
26. Professional Nursing
a. Private Duty Nursing.
Coverage is not provided for the first week of private duty nursing (otherwise covered) Incurred in any
Calendar Year. Covered Expenses will be reduced by these charges and Plan benefit determination will be
based on the balance.
Benefits are available for private duty nursing services for short term skilled nursing care ordered by
the attending Physician and found Medically Necessary to manage the care of acutely ill patients.
Expenses for care ordered primarily at the request of relatives, Household Members or other non-
medical professional persons will not be paid. Services must be provided by, and must require the
skills of, a registered nurse (RN). If confined, care must be of such intensity that the Hospital nursing
staff could not be expected to render such care. Shortage of nursing staff does not establish Medical
Necessity for private duty nursing. Benefits will be available for a licensed practical nurse if the
Doctor certifies that Registered Nurses were unavailable for a shift or portion of an approved plan of
twenty-four hour nursing care. Benefits are not payable for Custodial or Maintenance Care or care that
is primarily assistance with daily living or other services that do not require the skills of an RN.
No benefit is paid for the first week of covered nursing services. After the first week exclusion,
covered nursing services are limited to five weeks for each Covered Person each Calendar Year. See
Section I - Summary of Benefits under Benefit Schedule A, Medical Expense Benefits for special
Percentage Copayments that apply to weeks two through six for covered private duty nursing.
b. Visiting Nurses. Part-time or intermittent short-term visiting nurse services are allowable when
rendered in the patient's home and ordered by the attending Physician. Care must be billed by a
certified visiting nurse agency or by a state or county visiting nurse service for professional nurse
services.
32. Acupuncture. Benefits are available for acupuncture services when rendered by a Certified Acupuncturist
and found Medically Necessary for the treatment of Illness or Injury. Coverage is limited to 12 office visits
for each Covered Person per Calendar Year. The 12-visit limit does not apply to services rendered as part
of the SSMC pilot program. Anesthesia for a covered surgical procedure is covered separately under
Anesthesia shown previously in this section. If acupuncture is rendered by an Out-of-Network Certified
Acupuncturist, services must be ordered by the attending Medical Doctor (M.D.). A statement of Medical
Necessity by the attending M. D. must be sent to the Claims Administrator to determine coverage.
33. Sleep Apnea Studies. Plan covers sleep apnea studies only when rendered as part of the pilot program at
the Sound Shore Medical Center-Sleep Center subject to Plan Network Copayment and Network Inpatient
Deductible. Expenses Incurred for sleep apnea studies rendered outside the Sound Shore Medical Center-
Sleep Center will not be paid.
34. Weight Control Program. Plan covers Outpatient weight control program only when rendered as part of
the pilot program at the Sound Shore - Weight Control Center subject to Plan Network Copayment.
Expenses Incurred for weight control programs rendered outside the Sound Shore Medical Center-Weight
Control Center will not be paid.
G. Miscellaneous Provisions
1. Voluntary or Elective Reproductive Sterilization. Benefits are available for voluntary or elective surgical
sterilization such as tubal ligation and vasectomy rendered for you or your eligible Spouse on the same basis as
treatment of an Illness or Injury. Dependent children are not eligible for this benefit. The reversal of voluntary
or elective sterilization is not covered, whatever the reason.
