SSMC Employee Health Benefit Plan
60
23. Weight Reduction/Diet Management /Exercise. Services or Supplies related to weight reduction or diet
management for treatment of obesity no matter what age, condition, diagnosis or prognosis of the patient
even if it is part of a treatment plan for another condition. Diet management, exercise programs or general
conditioning programs for any condition even if ordered by a Physician. Exceptions: Limited coverage
specifically included in the Plan for diabetic education; SSMC pilot program for weight control; and for
diet medications for morbid obesity that are specifically included under Prescription Drug Expense
Benefits.
24. Inpatient Room and Board/Private Room. Room and board charges in any facility during a period when
the Covered Person (patient) is not physically present. Private room charges more than the Average Semi-
private Room Rates no matter why private room used. Room and board charges for a Friday or Saturday
admission date unless significant medical treatment is given on these days. Significant treatment includes
care not normally connected with room and board and general nursing.
25. Hospital Non-Acute Care Area. Room and Board and general nursing charges by a Hospital made during
an Inpatient stay or portion of an Inpatient stay for special non-acute level of care areas, by whatever name
called. These areas include, but are not limited to, areas designated as Skilled Nursing Facility,
convalescent or other non acute care center, Hospice, Substance Abuse treatment center, ambulatory
surgical center, Birth Center, partial Hospitalization, adult or child day or night care center, halfway house,
vocational Rehabilitation center or any other area of a Hospital that renders services on an Inpatient basis
for other than acute care of a sick or injured person. Benefits for a center that is part of a Hospital and
meets the definition of a covered facility are payable at the coverage level for that facility not the coverage
level for a Hospital.
26. Inpatient Custodial/Non-Acute Care/Long Term Care/Partial Hospitalization (day or night care).
Services or Supplies related to any part of an Inpatient stay that is primarily for physical checkups, physical
therapy, hydrotherapy, occupational therapy, diagnostic testing, Custodial, residential, sanitarium type, rest
cures or for environmental change. Services or Supplies related to partial Hospitalization (adult or child day
or night care in any facility, by whatever name called). Services or Supplies given in a place of rest, a
place for the aged, a nursing home or in an education facility, a place mainly for care of alcoholism, drug
addiction, mental disorders or tuberculosis unless facility meets Plan requirements for Skilled Nursing
Facility benefits, Substance Abuse Facility benefits and Hospice benefits. Services or Supplies related to
any portion of an Inpatient stay for care that cannot reasonably be expected to lessen the patient's disability
enabling him or her to leave an institution unless part of an approved Hospice plan of care.
27. Inactive Care/Custodial/Maintenance Care. Services or Supplies related to Inpatient or Outpatient care
that is not expected to improve the Covered Person's condition or related to care found Custodial or
Maintenance according to Plan provisions; long term or other care that does not, or cannot reasonably be
expected to, lessen the patient's disability enabling him or her to leave an institution unless care meets the
Plan requirements for Hospice care.
28. Reversal Sterilization Procedures. Services or Supplies related to the reversal of elective or voluntary
sterilization procedures, whatever the reason.
29. Artificial Contraception / In-vitro / Artificial Insemination/Reproduction. Services or Supplies
related to contraception procedures which are used to induce or enhance the probability of conception such
as artificial insemination, in-vitro fertilization, and any other services by whatever name called unless due
to medical condition of the covered female or due to abnormal male (Spouse) factors contributing to the
infertility. Plan also excludes procedures to facilitate Pregnancy in Dependent children or to facilitate a
surrogate Pregnancy.
