SSMC Employee Health Benefit Plan
90
EFFECTIVE DATE OR EFFECTIVE DATE OF COVERAGE - The date coverage is effective with
respect to an eligible and enrolled Employee or Dependent, after designated Waiting Periods. See Waiting
Periods.
ELIGIBLE DEPENDENTS - See Dependents.
ELIGIBILITY WAITING PERIOD - See Waiting Period.
EMERGENCY CARE CENTER See Urgent Care Facility.
EMERGENCY MEDICAL CARE - Treatment of a serious medical condition or behavioral condition after
the onset of acute symptoms that were sudden and of such severity and/or pain that a prudent person,
possessing an average knowledge of medicine and health could reasonably expect that the absence of
immediate medical attention could result in placing the person in serious jeopardy (or others if severe
behavioral condition), impairment to bodily function, dysfunction of any organ, or serious disfigurement.
EMPLOYEE - Any person who is considered an eligible Employee according to criteria established by the
Plan Administrator as set forth in Section II - Eligibility and Enrollment. It does not mean persons without
employment status, such as former employees that have been retired, terminated or laid off, unless continuing
coverage during an authorized leave of absence.
ENROLLEE OR COVERED ENROLLEE - An Employee or COBRA participant under whose social
security number enrollment is made.
ERISA - Employee Retirement Income Security Act of 1974 (ERISA), as amended.
EXPERIMENTAL See Investigative and Experimental.
EXTENDED CARE FACILITY - See Skilled Nursing Facility.
HAZARDOUS PURSUIT - An activity which involves or exposes an individual to risk of a degree or nature
not customarily undertaken in the course of the employee's customary occupation with his or her employer or
in the course of the class of leisure time activities commonly considered as involving unusual or excessive
risks. Such activities include, but are not limited to, hang gliding, sky diving, use of all terrain vehicles, rock
climbing, use of explosives, automobile or airplane or speedboat racing, bungee jumping, river running or
racing and travel to countries with advisory warnings.
HEALTHCARE PROVIDER - See Provider.
HOME HEALTH CARE AGENCY - A licensed agency or Hospital that has been issued a current
operating certificate as a certified home health agency by the New York State Department of Health. Outside
New York State, the agency must have a similar operating certificate issued by the state of jurisdiction; or be
certified by Medicare as a participating Home Health Care Agency.
HOME HEALTH CARE PLAN - A plan to provide out of Hospital care to a person rendered by an
approved Home Health Care Agency. To qualify, the established care plan must be approved in writing by an
attending Physician who certifies that the person would require confinement in a Hospital or convalescent
nursing home/Extended Care Facility/Skilled Nursing Facility if he did not have the care and treatment stated
in the care plan. The patient must remain under the supervision and care of the attending Physician during the
period home health care is provided.
HOSPICE OR HOSPICE AGENCY - An organization that has an appropriate operating certificate issued
by the New York State Department of Health to provide Hospice care and meets the standards of the National
Hospice Organization. Outside New York State, the Hospice organization must be duly licensed and certified
under criteria similar to those used in New York by a state agency in the state where the Hospice care is
provided; or Medicare must approve it; and it must meet the standards of the National Hospice Organization.
