SSMC Employee Health Benefit Plan
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COVERED EXPENSES - Allowable Fees charged by Covered Providers for medical Service or Supplies
that are covered according to Plan provisions, limitations and exclusions. The Enrollee or participant is
responsible for payment of any expenses not Covered by the Plan.
COVERED FAMILY MEMBER -The Enrollee and his or her Eligible Dependents enrolled in the
Enrollee's family coverage.
COVERED PERSON - Any person eligible and enrolled for benefits or coverage under this Plan, according
to Plan provisions, limitations and exclusions.
COVERED PROVIDER - See Provider
COVERED SERVICES OR SUPPLIES - See Services or Supplies.
CUSTODIAL OR CUSTODIAL CARE -Any institutional, Outpatient, or professional care that is not for
diagnosis or treatment of an Illness or Injury. Care is also Custodial when it is primarily to meet personal
needs. Examples of Custodial Care include, but are not limited to, assistance in the activities of daily living
(such as help in walking, getting in and out of bed, bathing, dressing, eating, and taking medicine);
administration of oral medications; assistance with supportive or Maintenance physical therapy; care due to
incontinence; turning and/or positioning in bed; acting as a companion or sitter; or nurse aide services. Long-
term care that cannot reasonably be expected to lessen the patient's disability enabling him or her to leave an
institution will be considered Custodial Care.
DEDUCTIBLE - The amount of Allowable Fees that must be paid by the Enrollee before the Claims
Administrator can determine certain benefits. See also Calendar Year Deductible.
DEPENDENT - An Enrollee's Spouse or an Enrollee's child who meets the conditions shown in Section II -
Eligibility and Enrollment.
DOCTOR - A person legally licensed to practice medicine (MD) or osteopathy (DO). See also Physician.
DRUG ABUSE FACILITY - See Substance Abuse Facility.
DURABLE MEDICAL EQUIPMENT - Equipment determined by the Claims Administrator to be
Medically Necessary for the treatment of disease or Accidental Injury or to improve body function lost as the
result of a disease, Injury or congenital abnormality which meets all of the following requirements. Durable
Medical Equipment must be:
1. Prescribed by a Physician who indicates the necessity of the item, including diagnosis, reason for use,
purpose, expected duration of use and a full description of item prescribed;
2. Non-aesthetic in nature;
3. Safe and effective for home use without medical supervision;
4. The most appropriate equipment or model for the reported condition. Deluxe equipment is not allowable
when standard equipment is available and medically adequate for the reported condition;
5. Made to stand extended and repeated use. Disposable Supplies may be allowed if required to operate the
medical equipment;
6. Required to replace body function lost or impaired due to disease, Injury or congenital abnormality or is
Medically Necessary to carry out necessary activities of daily living connected to the patient's health or
hygiene with little to no aid from others. It must not be solely for the convenience of the patient or the
patient's caregiver; and
7. Used to serve a medical purpose. It must not be useful without disease or Injury and must not be for
comfort, used to enhance the patient's home or environment, communication, alter air quality or
temperature or for exercise or training.
