SSMC Employee Health Benefit Plan
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2. Infertility/Reproductive Care/In-vitro Fertilization / Artificial Insemination. Benefits are available
for an Approved Plan of Care for infertility or artificial conception treatment for the Employee or his/her
Spouse. This coverage is not available to Dependent Children. Benefits will be provided for covered
services in the same manner as an Illness based on type of services received subject to Plan Copayments,
Deductible and Maximums. Available benefits will be limited to $10,000 per Covered Person each
Calendar Year.
To obtain coverage approval for a course of treatment, the Doctor must provide a statement of Medical
Necessity including details on condition, medical history, previous treatment and proposed treatment before
the care begins. The Claims Administrator will advise whether coverage is available according to Plan
limitations and exclusions.
Coverage is limited to an approved course of Outpatient treatment in a facility or clinic that is licensed or
certified for the services it provides by the state in which it operates. Treatment must be done on an
Outpatient basis in a facility or clinic that is licensed or certified for the services it provides by the state in
which it operates. Inpatient infertility care will not be paid. Coverage includes services and Supplies for
hormonal therapy, artificial insemination, sonograms, in vitro procedures and other treatment that meets the
protocol established by the American College of Obstetricians and Gynecologist. Treatment must be found
Medically Necessary due to the medical condition of the covered female or due to abnormal male (covered
female's Spouse) factors contributing to the infertility. Coverage includes procurement of eggs, sperm, or
embryos from or donated by the patient or by his/her Spouse or other donor when part of an approved
course of treatment
Coverage is not provided for infertility or artificial conception services and Supplies related to surrogate
pregnancies. Expenses related to the freezing and storage of eggs, sperm, or embryos are not covered,
whatever the reason. Benefits are not available for treatment of infertility caused by menopause or
climacteric syndromes nor for reversal of sterilization procedures.
Expenses related to surgical correction of a diagnosed medical condition are covered separately on the
same basis as any other Illness. Coverage for a resulting Pregnancy will be considered separately as
maternity care.
3. Transplants/Autologous Bone Marrow/Stem Cell
Unless otherwise specifically included, transplants are considered Investigative or Experimental unless specifically
included for Medicare coverage by the Centers for Medicare & Medicaid Services (CMS). Transplants must meet
the CMS criteria for coverage to be considered for coverage under this Plan. Benefits are not available for
expenses related to transplants that have not been approved by CMS or that fail to meet CMS criteria for coverage.
Plan Coverage for Hospitals will be based on the same criteria set forth by CMS criteria. If CMS restricts coverage
for a transplant to approved Hospitals only, then this Plan will only cover those transplants when rendered in the
Medicare approved Hospital.
Benefits are available for expenses related to non-Experimental organ or tissue transplants the same as any
other Illness. Coverage includes non-Experimental organ or tissue transplants that are Medically Necessary
based on established health and age standards generally accepted by the national medical professional
community and include the following:
a. Recipient Expenses. Coverage for a Covered Person receiving a transplant (recipient) includes all
Medically Necessary care and treatment related to Covered organ transplants including, but not limited
to; pre-transplant care including evaluation, diagnostic tests and x-rays by the transplant Hospital;
organ search and procurement/tissue harvest and preparation; recipients transplant Surgery and
recovery; and post discharge care; and any other medical care found Medically Necessary according to
Plan provisions and limitations.
b. Donor Expenses. Coverage for the person receiving the organ(s) includes expenses Incurred by the
live donor(s) for expenses related to procurement of an organ and for transportation of the organ(s), to
