SSMC Employee Health Benefit Plan
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14. Dental Care. Services or Supplies related to care or treatment of the teeth, gums or alveolar process
(dental work), such as dental caries (tooth decay), extractions whether simple or surgical, periodontics,
bridges, crowns, orthodontia, implants or other services considered dental in nature. Exception: Charges
by a dentist or Physician for care otherwise considered medical such as reduction of fractures of the jaw or
facial bones, surgical correction of cleft lip, cleft palate, removal of stones from salivary ducts, bony cysts
of the jaw, torus palatinus, leukoplakia or malignant tissues, treatment and Surgery for joint disorders,
freeing of muscle attachments and limited dental care specifically included in the Plan.
15. TMJ Syndrome. Non-surgical services, adjustments, appliance or Supplies related to for treatment of
temporomandibular joint dysfunction (TMJ) or similar disorders. Exception: One appliance and six non-
surgical treatments specifically included in the Plan.
16. Anesthesia. Services or Supplies for the administration of anesthesia for any Surgery or treatment not
covered by the Plan.
17. Midwife/Doctor Duplicate Services. Services that are duplicative because they are provided by both a
nurse midwife and Doctor.
18. Surgical Assistance. Expenses billed for surgical assistance in a Hospital if the Hospital has qualified staff
Physicians to provide such assistance. Expenses billed for surgical assistance by Providers other than
qualified surgeons.
19. Educational/Cognitive/Training/Therapy for Developmental and Birth Defects. Services or Supplies
related to special education, training, vocational training or cognitive therapy for any reason, for
occupational, physical, speech therapy, psychological or other therapy that is primarily directed at
educational, mental or physical development for learning deficiencies, mental retardation, developmental
disorders, birth defects, autism, spina bifida, educational or occupational deficits or perceptual and
conceptual dysfunction; or similar disorders. This applies whether or not associated with manifest Mental
Illness or other disturbances. Services or Supplies considered remedial or educational. Services or
Supplies that any school system is required to provide under any law unless the law makes this Plan
primary for expenses otherwise covered by the Plan. This applies even if the Covered Person, parent or
guardian does not seek provision of the Services or Supplies through the school system.
20. Occupational Therapy. Services or Supplies related to occupational therapy unless part of an Approved
Plan of Care for services by a Home Health Care Agency, Hospice Agency, or Inpatient Care by a Hospital
or Skilled Nursing Facility, Convalescent Care Facility, Rehabilitation Facility or short term occupational
to regain skills lost due to Illness or Injury as specifically included in the Plan..
21. Counseling/Analysis/Support Groups. Services or Supplies primarily directed at raising the level of
consciousness, social enhancement, counseling limited to everyday problems of living such as, marriage
counseling, family counseling, pastoral counseling; gender identity counseling, sex therapy, or support
groups. Exception: Limited coverage for bereavement counseling specifically included in the Plan.
22. Foot Care/Shoes/Orthotics/Supports. Services or Supplies related to routine foot care such as cutting or
removal of corns, calluses, nails, routine hygienic care, or preventive Maintenance Care (ordinarily within
the realm of self-care). Treatment and orthopedic shoes, foot Orthotics or other supportive foot devices for
weak, strained, flat, unstable or unbalanced feet, metatarsalgia, bunions or subluxation of the feet despite
underlying pathology. Exceptions: The removal of nail roots and open cutting corrective procedures.
Routine foot care ordered by a medical Doctor for patients with metabolic disorders or peripheral vascular
disease or orthopedic shoes or appliances that are custom made and otherwise included under Covered
Medical Expenses.
