SSMC Employee Health Benefit Plan
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HOSPICE CARE PLAN - A plan of care for treatment of a terminal patient that is established and
conducted by the Hospice Agency under the supervision of a Physician.
HOSPICE UNIT - A facility or separate Hospital unit that provides treatment under a Hospice care plan and
admits patients who are not expected to live more than six months due to terminal Illness.
HOSPITAL - A short term acute care institution that makes charges and is engaged primarily in providing
medical care and treatment to sick and injured persons on an Inpatient or Outpatient basis at the patient's
expense, which fully meets all of the following requirements:
1. It is an institution operating and licensed according to the law of the jurisdiction in which it is located
concerning institutions identified as Hospitals;
2. It is primarily engaged in providing diagnosis, treatment and care of injured or sick persons on an
Inpatient basis and receives compensation from its patients. It maintains organized departments on the
premises for major operative Surgery, and it provides twenty-four (24) hour nursing services by or under
the full time supervision of professional registered nurses;
3. If located in New York State, has in effect a Hospitalization review plan, applicable to all patients, that
meets at least the standards set forth in section 186 (k) of United States Public Law 89-87 (42 USCA
1395x (k)). If not located in New York State, it is a Hospital accredited by the Joint Commission on
Accreditation of Health Care Organizations as an acute care facility.
4. It is not, other than incidentally, a Skilled Nursing Facility, Extended Care Facility, convalescent facility,
Extended Care Facility, a nursing home, a place for rest, Custodial Care, education or Rehabilitation care,
for the aged, a place for the mentally ill or emotionally disturbed, or a place for the treatment of drug
addiction or alcoholism.
HOSPITAL MISCELLANEOUS - Charges made by a Hospital on its own behalf for medical Service or
Supplies given to a Covered Person either on an Inpatient or Outpatient basis. Such Service or Supplies must
be Medically Necessary for the patient's treatment. Room and board and professional services (including
intensive nursing care by whatever name called), are not considered Hospital Miscellaneous expenses
whether given under the direction of the Hospital or otherwise.
HOUSEHOLD MEMBER - Any person sharing a common abode as part of a single family unit, including
domestic employees and others who live together as part of a family unit, but not including a mere roomer or
boarder.
ILLNESS - Any Non-occupational Injury, sickness, disease, bodily disorder, functional mental disorder that
manifests treatable symptoms and requires the professional medical treatment of the affected Covered Person.
IMMEDIATE RELATIVE of patient or Enrollee - Any of the following:
1. Spouse of the patient or Enrollee;
2. Natural or adoptive parent, child or sibling;
3. Stepparent, stepchild, stepbrother or stepsister;
4. Father-in-law, mother-in-law, brother-in-law, or sister-in-law;
5. Grandparent or grandchild; or
6. Spouse of grandparent or grandchild.
INCURRED OR INCURRED EXPENSES - Those Services or Supplies given to or received by a Covered
Person. Such expenses shall be considered to have accrued at the time or date the servic e or supply is actually
provided.
INJURY - See Accidental Injury.
INPATIENT OR INPATIENT CARE - The period during which a Covered Person is treated in a Hospital,
skilled nursing or Rehabilitation Facility, Substance Abuse Facility or any other Covered facility as a
registered bed patient for whom room and board charges are made.
