SSMC Employee Health Benefit Plan
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BIRTH CENTER - A free standing facility or Hospital center established, equipped and operated, according
to the applicable laws of the jurisdiction in which it is located, or accredited by either the Joint Commission
for Accreditation of Health Care Organizations or the Accreditation Association for Ambulatory Care; or by
Medicare, to provide Inpatient and Outpatient mater nity care for uncomplicated pregnancies, including
routine prenatal care, routine full-term delivery, and immediate postpartum care. The facility must have an
agreement with a local Hospital to accept emergency admissions of its maternity patients with serious
complications.
CALENDAR YEAR - A period of twelve consecutive months, starting at 12:01 A. M. of January 1 and
ending at midnight on December 31.
CALENDAR YEAR DEDUCTIBLE - The amount of allowable expenses that must be paid by the Enrollee
each Calendar Year before the Claims Administrator can determine certain benefits. See also Deductible.
CERTIFIED ACUPUNCTURIST. A healthcare professional who is currently accredited by the National
Certification Commission for Acupuncture and operating within the scope of practice according to the
certification and jurisdiction of his/her state acupuncturist license.
CERTIFIED MENTAL HEALTH NURSE: A licensed registered professional nurse who is certified by
state regulatory agency for mental health care or, if not state regulated, must be certified by the American
Nurses Credentialing Center as a clinical specialist in child/adolescent or adult mental health care.
CERTIFIED MENTAL HEALTH SOCIAL WORKER: A licensed social worker who has been certified
by the New York State Board for Psychiatric Social Work or similar qualifications outside New York.
CERTIFIED NURSE ANESTHETIST - A licensed registered nurse who is currently accredited by the
American Association of Nurse Anesthetists Council on Accreditation of Nurse Anesthetists as a certified
registered nurse anesthetist (CRNA) and operating within the scope of practice according to the certification
and the jurisdiction of the state license.
CERTIFIED SUBSTANCE ABUSE COUNSELOR: A healthcare professional who is certified by the
New York State Office of Alcoholism and Substance Abuse Services (OASAS) for the Outpatient treatment
of chemical dependency (Substance Abuse). For services given outside New York, the counselor must be
certified by a state agency similar to the New York State OASAS.
CLAIMS ADMINISTRATOR - The person or organization under contract with the Plan Administrator for
the processing and determination of benefits under the Plan.
COBRA - The continuation of Plan coverage according to Federal regulations under the Consolidated
Omnibus Budget Reconciliation Act of 1986 and subsequent Federal COBRA regulations affecting this type
of Plan.
COLLEGE OR UNIVERSITY - An institution listed in the current American Council on Education
publication of Accredited Institutions of Post-Secondary Education.
CONVALESCENT CARE FACILITY - See Skilled Nursing Facility.
COPAYMENT - That figure shown as a percentage used to compute the benefits payable or a dollar amount
applied to Allowable Fees. The Covered Person is responsible for payment of any Copayment balance not
paid by the Plan.
COSMETIC / COSMETIC PROCEDURE - Services or Supplies related to procedures performed
primarily for psychological purposes or to preserve or improve a person's appearance r ather than to restore
the anatomy and/or functions of the body which are lost or impaired due to Illness or Injury.
