SSMC Employee Health Benefit Plan
2
SSMC has designed a Plan that gives you health benefits for a broad range of medical and dental services. A
number of features have been included in the Plan to manage costs for both you and SSMC and to ensure that
the health care you receive is within Plan guidelines. The Medical Expense Benefits shown in this SPD are
available to eligible and enrolled Employees and their eligible and enrolled Dependents.
The Master Plan Document of the SSMC Employee Health Benefits Plan consisting of the SPD, the terms
of the Plan and any Amendments to the Plan are maintained and on file with the Plan Administrator.
The provisions of this Plan may only be determined accurately by reading the Master Plan Document.
To the extent, the SPD or other Plan information is inconsistent with the provisions of the Master Plan
Document, the terms of the Master Plan Document will govern.
This SPD and the benefits shown are subject to change by the Plan Administrator, SSMC, anytime and at its
sole discretion. The Plan Administrator/ Plan Sponsor intends to continue this Plan, but reserves the right to
cancel it anytime without the consent of Covered Persons. Any changes or cancellations will not be retroactive.
You will be notified of any reduction in benefits within 60 days of such changes. In addition, it is understood
that all professional services are the sole responsibility of the specific health care Provider and that SSMC
acting as Plan Administrator or as Plan Sponsor and the Claims Administrators have no responsibility or
liability whatsoever to persons who are Enrollees or participants in this Plan with respect to the provision of any
professional services.
A. Plan Funding
SSMC has hired POMCO and EHS as Claims Administrators to process claims under the Plan. The Claims
Administrators do not act as insurers, but merely as Claims processors. Claims for benefits are sent to the
Claims Administrators. They process the claims, then request and receive funds from SSMC to pay the claims,
and make payment on the claims to Hospitals, other Providers and the Plan Participants, as appropriate. SSMC
is ultimately responsible for providing Plan benefits, not the Claims Administrators. Benefits are paid directly
out of the general assets of SSMC. There is no special fund or trust or insurance from which benefits are paid.
B. Health Claims Administrator
POMCO administers your Preventive or Well Care Benefits, Hospital Expense Benefits and Medical Expense
Benefits. Prescription Drug Expense Benefits are administered separately. Claims should be mailed directly to
POMCO for benefit determination. If you have any questions or concerns about your coverage, you can phone
POMCO or your Human Resources Department. Cla im forms can be obtained from the SSMC Human
Resources Department or from POMCO. Refer to Section VIII - Claim Submission and Review Procedures
for details on submitting your claims.
POMCO
P.O. Box 6329
Syracuse, NY 13217
Phone: Toll-free # 1-800-501-9536
C. Benefit Management Program Administrator
POMCO administers the Benefit Management Program. Refer to Section III - Benefit Management Program
for full details of program requirements. This is a mandatory program. Failure to follow the requirements of
this program could result in a reduction of your Plan benefits. A phone call to the POMCO Medical
Services Department is required before scheduled Inpatient admissions to a Hospital or other Inpatient
facility, or within 48 hours after an emergency or urgent admission; when maternity stays exceed 48
hours after normal delivery or 96 hours after cesarean section; when Newborn care exceeds 96 hours
after birth; or before home health care services begin.
