SSMC Employee Health Benefit Plan
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SECTION X - DEFINITIONS
Certain words and phrases applicable to or used in this SPD are listed below with the definit ion or
explanation of the manner in which the term is used for the purpose of the Plan. Masculine pronouns, if used
in this SPD, shall include masculine or feminine gender, unless the context shows otherwise.
ACCIDENTAL INJURY Non-occupational bodily Injury caused by an event that is sudden and not
foreseen, and is exact as to time and place. Injury must be unexpected and unavoidable. Chewing is not
considered an accident. The breakdown or fracture of Natural Teeth or other conditions caused by chewing
will not be considered Accidental Injury.
ACUPUNCTURIST See Certified Acupuncturist.
ALCOHOL FACILITY - See Substance Abuse Facility.
ALLOWABLE FEES - The Usual, Customary and Reasonable Charges as determined according to Plan
provisions for cover ed medical services rendered and billed by a Out-of-Network Providers. If billed by a
Network Providers, Allowable Fees means the Network scheduled allowance or negotiated discount based on
the Network agreement with the Plan Administrator. If Medicare is primary the Allowable Fees could be
based on Medicare allowance or limiting charges. The Plan will not pay charges that exceed Allowable Fees.
The Enrollee or Covered Person is responsible for payment of any charges that are not allowed under the
Plan.
ALLOWABLE SERVICES OR SUPPLIES - See Covered Services or Supplies.
AMBULATORY SURGERY - Surgery rendered on other than an Inpatient basis. For example: in a
Physician's office, a clinic, Outpatient department of a Hospital, ambulatory facility or other Outpatient
location.
AMBULATORY SURGICAL FACILITY - A specialized facility operated, according to the applicable
laws of the jurisdiction in which it is located; or accredited by the Joint Commission for the Accreditation of
Health Care Organizations or the Accreditation Association for Ambulatory Care; or approved by Medicare,
to render Outpatient services for Ambulatory Surgery. The facility must be organized and used mainly for
Outpatient Surgery, have a staff of surgeons and anesthesiologists, and full-time professional nurses. If the
center is part of a Hospital it will not be considered an Ambulatory Surgical Facility.
AMENDMENT or Amended - A formal document showing a change, revision, deletion, or addition to the
Master Plan Document and/or Summary Plan Description by the Plan Administrator and duly executed after
adoption by any of the following: The SSMC Board of Governors; The President of SSMC; Any individual or
individual who has been identified by virtue of his or title with SSMC who has been authorized by the SSMC
Board of Governors or the President of SSMC to amend the Plan. Amendments apply to eligible persons
including those persons covered before the Amendment becomes effective, unless otherwise specified.
APPROVED PLAN OF CARE - Any service or course of treatment approved for benefits by the Claims
Administrator under the terms and limitations of the Plan.
AVERAGE SEMI-PRIVATE ROOM RATES - The standard semi-private rate for room and board charges
by a Hospital or other Covered Inpatient health facility. If the Inpatient facility does not have a semi-private
rate, the rate shall be deemed to be 80% of the room and board charges made by the facility for its lowest
priced private room accommodations. If the facility has several semi-private rates, the prevailing, or the most
common rate, shall be used. Semi-private accommodations are usually rooms with two or more beds.
