ANGLO MEDICAL SCHEME. BENEFITS Effective 1 January The following words or expressions have the following meanings

Transcription

1 1 BENEFITS Effective 1 January Definitions The following words or expressions have the following meanings 1.1 "annual family limit" the total benefit amount that is available to a member family, in respect of a particular benefit, in any one financial year; 1.2 "beneficiary" - a member, adult dependant or child dependant; 1.3 "chronic condition" is a medical condition that is either a prescribed minimum benefit (PMB) condition as listed in Annexure A to the Regulations; or a Non-Prescribed minimum benefit (Non-PMB) condition recognised by the Board of Trustees from time to time; a prescribed minimum benefit ( PMB ) condition contemplated in the Diagnosis and Treatment Pairs listed in Annexure A to the Regulations, that includes the diagnosis, medical management and medication to the extent that it is provided for in terms of a therapeutic algorithm as prescribed for the specified chronic condition. This includes the prescribed minimum benefit chronic

2 2 disease list for the following chronic conditions: Addison s disease; Asthma; Bipolar mood disorder; Bronchiectasis; Cardiac failure; Cardiomyopathy disease; Chronic renal disease; Chronic obstructive pulmonary disorder; Coronary artery disease; Crohn s disease; Diabetes insipidus; Diabetes mellitus Type 1 and 2; Dysrhythmias; Epilepsy; Glaucoma; Haemophilia; Hyperlipidaemia; Hypertension; Hypothyroidism; Multiple sclerosis; Parkinson s disease; Rheumatoid arthritis; Schizophrenia; Systemic lupus erythematosus; Ulcerative colitis; or a Non-Prescribed minimum benefit (Non-PMB) chronic condition recognised by the Board of Trustees, that provides for the payment of chronic medication according to a Chronic Medication Reference Price List (CMRPL) for the following conditions: Acne; Allergy management; Alzheimer s disease; Anaemia (non-pmb); Ankylosing Spondylitis; Anxiety Disorder (chronic); Atopic Dermatitis (Eczema); Attention Deficit Disorder; Auto - immune Disorders (non-pmb); Cystic Fibrosis (non-pmb); Cystitis (chronic); Degeneration of the Macula; Depression (nonpmb); Diverticular Disease of the Intestine (non-pmb); Fibrous Dysplasia; Gastro-oesophagael Reflux Disease; Gout; Hidradenitis Suppurativa; Huntington s Disease; Liver Disease (Chronic non-pmb); Menieres Disease; Migraine; Motor Neurone Disease; Muscular Dystrophy & other (non-pmb); Myopathies; Narcolepsy; Obsessive Compulsive Disease; Osteoarthritis; Osteopaenia; Osteoporosis (non-pmb); Paget s Disease;

3 3 Pancreatic Disease (non-pmb); Peptic Ulcer (non-pmb); Polymyositis (non-pmb); Polyneuropathy (non-pmb); Psoriasis (non-pmb); Pulmonary Intestinal Fibrosis (non-pmb); Sarcoidosis (non-pmb); Systemic Sclerosis; Tourette s Syndrome; Trigeminal Neuraligia; Urinary Calculi (chronic nonpmb); Urinary Incontinence (non-pmb); 1.4 CMRPL Chronic Medication Reference Price List a list of fees in respect of medication for chronic conditions, determined by the Scheme from time to time; 1.5 designated service provider - a healthcare provider selected by the Scheme as the preferred provider for the diagnosis, treatment and care of a PMB condition; 1.6 NHRPL National Health Reference Price List - list of fees in respect of relevant health services, published by the Minister of Health or any other appointee as designated by the Minister from time to time; 1.7 Scheme Reimbursement Rate (SRR) is equivalent to: the negotiated rate for hospitals and designated or preferred service provider; % of the National Health Reference Price List (NHRPL) for healthcare services as published by the Department of Health on 23 rd December 2008; plus an inflationary factor of 8.5% for 2010;

4 the dispensing fee for medicines dispensed as agreed by the Board of Trustees from time to time; 1.8 single exit price - the price of a specific drug, determined annually by the Department of Health. 2 Pro-ration of benefits A member or registered dependant who is admitted to the Scheme during the course of a financial year shall have his/her benefits pro-rated. The benefits to which he/she is entitled will therefore be adjusted in proportion to the period of his/her membership, which will be calculated from the admission date to the end of that financial year. 3 Management Programmes The following management programmes have been adopted by the Scheme The Chronic Medication Programme ChroniCare Network Programme - a programme which authorises the use of medication for a chronic condition by members and their registered dependants. The programme involves confirmation of the diagnosis and severity of the chronic condition, as well as determination of the clinical appropriateness and proven long-term cost-effectiveness of the medicines prescribed;

5 5 3.2 Hospital Benefit Management Programme - a programme which involves the approval, and ongoing monitoring, by or on behalf of the Scheme, of the hospital treatment of certain medical conditions; 3.3 Disease/Condition Management Programme - a programme which incorporates clinical protocols for containing costs and/or ongoing review and monitoring of patients with a defined medical condition. Specific Disease/Condition Management Programmes, which have been adopted by the Scheme include The HIV/AIDS Management Programme; The Renal Disease Management Programme The Maternity Management Programme; The Oncology Programme; The Diabetes Management Programme; and The Alcohol and Drug Dependency Programme. 3.4 If the Scheme has adopted a management programme for a particular condition, the benefit in respect of such condition is subject to pre-authorisation and registration with the relevant management programme. A co-payment will be imposed if a beneficiary voluntarily obtains such

6 6 services from a provider other than a designated service provider. This co-payment will be the difference between the actual cost incurred and the cost that would have been incurred had the service been obtained from a designated service provider. In the case of diabetic members, the co-payment will be 20% of the NHRPL for services rendered or 20% of the CMRPL for medicines dispensed. 4 Pre-authorisation Where a benefit is subject to pre-authorisation, a beneficiary must obtain the authorisation of the Scheme (or, in the case of ambulance services, the designated service provider) prior to obtaining the relevant health service to which the benefit relates. A beneficiary who fails to obtain such prior authorisation will, except in the case of an emergency medical condition, and prescribed minimum benefit condition, be liable for the full cost of the relevant health service. 5 Excess Tariff Cover (GAP) Subject to the requirements of the Hospital Benefit Management Programme and the provisions of Annexure C, if a beneficiary is hospitalised, or in an accredited doctor s room facility, all in-hospital professional services relating to benefits (other than the hospitalisation benefit and Pathology and Radiology), will not be subject to the normal limit but will be paid at a maximum of 200% of the Scheme Reimbursement Rate (SRR).

7 7 6 Benefits The benefits to which a member is entitled in respect of himself/herself, and each of his/her registered dependants, are set out below. Where a benefit is subject to available savings in the member s personal medical savings account ( PMSA ) the benefit shall be - paid at the actual amount charged by the provider, subject to a limit equal to the available savings in that member s PMSA; and - paid, firstly, out of any accumulated credit that the member may have and then out of his/her advance savings for that financial year. 6.1 PRESCRIBED MINIMUM BENEFITS A beneficiary is entitled to 100% of the cost of the diagnosis, treatment and care of the PMB conditions contemplated by the Act, provided that any services in relation to PMB conditions are obtained from a designated service provider. A co-payment will be imposed if a beneficiary voluntarily obtains such services from a provider other than a designated service provider. This co-payment will be the difference between the actual cost incurred and the cost that would have been incurred had the service been obtained from a designated service provider. No co-payment will be imposed on a member if the service was involuntarily obtained from a provider

8 8 other than a designated service provider. A co-payment as contemplated above will be imposed in those instances where a beneficiary voluntarily declines a chronic drug that is specified on the CMRPL and chooses to use another drug instead. 6.2 ALCOHOL AND DRUG DEPENDENCY Subject to registration on the Alcohol and Drug Dependency Management Programme, and SANCA, the designated service provider, a beneficiary is entitled to the following: Hospitalisation Rate (SRR), as negotiated between the Scheme and the hospital concerned, for a maximum of twenty-one days of hospitalisation, for alcohol or drug dependency, per annum, subject to Prescribed Minimum Benefits Professional Services Inside Hospital Rate (SRR) for professional services rendered in hospital in connection with the treatment of alcohol or drug dependency, subject to Prescribed Minimum Benefits.

9 Professional Services Outside Hospital Subject to available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for professional services, rendered outside hospital, in connection with the treatment of alcohol or drug dependency, except in the case of a PMB. Where a beneficiary elects not to participate in the Alcohol and Drug Dependency Management Programme, the benefit allowed will be subject to Rule 6.1 above. 6.3 ALTERNATIVE HEALTH CARE PRACTITIONERS Subject to available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for the following homeopathy consultations; chiropractic consultations, including x-rays; and naturopathy consultations. 6.4 AMBULANCE SERVICES Rate (SRR), or the actual cost, if lower, of emergency transport and other

10 10 ambulance services. Any use of ambulance services (whether in respect of a PMB condition or not) is subject to pre-authorisation by Netcare 911 who is the designated service provider, except in the case of an emergency medical condition. In such an event, a member must notify Netcare 911, the designated service provider on the next working day after the emergency event, failing which he/she may be required to pay the total cost of service. 6.5 AUXILIARY HEALTH SERVICES Subject to available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider for the following auxiliary health services audiology; physiotherapy; clinical psychology; orthoptics; speech and occupational therapy;

11 chiropody and podiatry services; dietician services; social services; and acupuncture. 6.6 BLOOD TRANSFUSIONS A beneficiary is entitled to 100% of the cost of blood transfusions, including the cost of material, blood and blood products, apparatus and operator s fees. 6.7 CONSULTATIONS AND VISITS Consultations Outside Hospital Subject to the exclusions in Annexure C, the Prescribed Minimum Benefits and the available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for consultations and visits, out of hospital, by general practitioners, nurse practitioners and medical specialists; Procedures performed during consultations and visits contemplated in 6.7.1, will be paid out of

12 12 the risk benefit at 100% of the Scheme Reimbursement Rate (SRR), or actual cost, whichever is the lower Consultations In Hospital Rate (SRR), or the actual cost, if lower, of consultations, visits and procedures in hospital, by general practitioners, nurse practitioners and medical specialists. 6.8 DENTAL Conservative Dentistry Subject to available savings in the member's PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for conservative dental services out of hospital, such as consultations, fillings, extractions, x-rays and prophylaxis Specialised Dentistry Subject to available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for specialised dentistry services such as gold, metal and porcelain inlays and foils; crown and bridgework; dentures; orthodontia; periodontal services; prosthodontic

13 13 services; if performed by a dentist or specialist dentist; osseointegrated implants or other similar tooth implants, including the cost of appliances and prosthesis, whether obtained from a hospital, dentist or other supplier. With the exception of osseo integrated implant surgery, dental hospitalisation in the case of trauma; patients under the age of seven years and impacted third molars is not subject to available savings in the member s PMSA but falls under the hospitalisation benefit of an entitlement to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower. 6.9 HOSPITALISATION General Rate (SRR) (inclusive of fixed fee procedures), as negotiated between the Scheme and the hospital concerned, for all services received in nursing homes, day clinics, unattached theatre units, private hospitals, and government and provincial hospitals Pre-Authorisation Any hospital admission is subject to pre-authorisation by the

14 14 Scheme, except in the case of an admission for an emergency medical condition. In such an event, a member must notify the Scheme on the next working day after the admission, failing which he/she may be required to pay the total cost of service for Non Prescribed Minimum Benefit admissions Co payments A co-payment of a minimum of R228 per day and a maximum of R684 per hospital stay, is payable by members in respect of all hospital admissions, including day cases. No co-payment will be due in respect of a PMB condition Ward Fees Rate (SRR), as negotiated between the Scheme and the hospital concerned, for general ward fees; and high care and intensive care unit fees, where occupation of such unit is certified by a medical practitioner as being clinically appropriate and necessary for the recovery of the patient.

15 Ward and Theatre Drugs and Appliances Rate (SRR), as negotiated between the Scheme and the hospital concerned, for ward and theatre drugs, surgicals and appliances that are prescribed and used while the beneficiary is resident in any nursing home, hospital or sanitorium, subject to in the case of prescribed drugs, the single exit price for such drugs; in the case of To Take Home drugs (TTOs), a limit of seven day s supply on discharge; and in the case of appliances, the annual family limit for medical and surgical appliances Theatre Fees and Materials Rate (SRR), as negotiated between the Scheme and the hospital concerned, for theatre fees, labour ward charges, dressings and materials used in theatre.

16 Company-owned Hospitals and Clinics A beneficiary is entitled to 100% of the all-inclusive fee, agreed to by the Board, charged by individual hospitals and clinics, and/or similar clinics or hospitals owned by any participating employer, whose medical and other services are recognised by the Board. Where a company-owned hospital or clinic is utilised, benefits will be allowed only where the services provided are consistent with the range of benefits provided in terms of the Rules Private Nursing A beneficiary is entitled to 100% of the price Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of private nursing in lieu of hospitalisation, provided that such services are pre-authorised by the Scheme Frail Care Rate (SRR) of medically related frail care services obtained at a registered frail care centre, subject to pre-authorisation by the Scheme and a limit of R per beneficiary per annum.

17 Hospice and Step Down Nursing Facilities Subject to pre-authorisation by the Scheme, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of services in a step down nursing facility; and care in a Hospice facility as an in-patient or as an outpatient, or Hospice Homecare services HIV/AIDS Subject to registration with the HIV/AIDS Management Programme and OPTIPHARM, the designated service provider, a beneficiary is entitled to % of the cost of services relating to the treatment or management of HIV/AIDS; and % of the cost of the single exit price plus Scheme Reimbursement Rate (SRR) for dispensing fee for medication for the treatment of HIV/AIDS, provided that the medication is obtained directly from the designated service provider. Where a beneficiary elects not to participate in the HIV/AIDS Management Programme, this benefit will be subject to Rule 6.1 above.

18 INFERTILITY Rate (SRR), or the actual cost, if lower, of the investigation and treatment of infertility, subject to the specific exclusions as reflected in Annexure C; and in the case of prescribed medicines for infertility, available savings in the member s PMSA, except in the case of a PMB MATERNITY All benefits relating to maternity are subject to registration on the Maternity Management Programme. Should a beneficiary not register on the Maternity Management Programme, the benefits shall be subject to available savings in the member s PMSA, except in the case of a Prescribed Minimum Benefit Ante-natal Consultations, and Post-natal Care A beneficiary is entitled to 100% of the price Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of anteand post-natal consultations and visits with general practitioners, nurse practitioners and obstetricians.

19 Hospital or Private Nursing Home (subject to Rule 6.1) Rate (SRR), as negotiated between the Scheme and the hospital concerned, for ante- and post-natal services provided by a hospital or nursing home Confinement in a Hospital (subject to Rule 6.1) Rate (SRR), as negotiated between the Scheme and the hospital concerned, for services provided for normal delivery, Caesarean section if medically appropriate and epidural surgery at a hospital or private nursing home Confinement at Home or in a Low-Risk Obstetric Unit Rate (SRR), or the actual cost, if lower, of a confinement rendered by a registered midwife at the home of the beneficiary, or at a low-risk Obstetric Unit Pregnancy Scans A beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of one

20 20 ultra sound pregnancy scan per pregnancy, or to the cost of additional scans authorised in terms of the Maternity Management Programme MAXILLO-FACIAL AND ORAL SURGERY Rate (SRR), or the actual cost, if lower, of maxillo-facial or oral surgery, if prescribed by a medical practitioner or dentist, subject to the following consultations are paid at the actual amount charged by the provider, subject to the available savings in the member s PMSA; benefits in respect of maxillo-facial surgery and anaesthetics are subject to the benefit for hospitalisation and pre-authorisation by the Scheme; benefits in respect of osseo-integrated implants, or similar tooth implants, are paid at the actual amount charged by the provider, subject to available savings in the member s PMSA MEDICAL AND SURGICAL APPLIANCES A beneficiary is entitled to 100% of the cost of medical and surgical appliances, excluding the appliances referred to in

21 21 paragraphs and , subject to pre-authorisation for appliances in excess of R500 per appliance and an annual limit per member family of R A beneficiary is entitled to 100% of the cost of wheelchairs, subject to pre-authorisation by the Scheme and a limit of R per beneficiary every two years A beneficiary is entitled to 100% of the cost of hearing aids, subject to a prescription from an Ear, Nose and Throat specialist for beneficiaries younger than 60years, as well as pre-authorisation by the Scheme and a limit of R per hearing aid per beneficiary every two years Subject to pre-authorisation by the Scheme, and Prescribed Minimum Benefits, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR) of oxygen when it is administered to save life, including the cost of hiring of apparatus used for the administration of oxygen MEDICINES A beneficiary is entitled to one month s supply in respect of medicines obtained on a prescription, for every prescription or repeat thereof.

22 Acute Medication Subject to available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider for prescribed acute medication obtained from a pharmacy or registered dispensing practitioner, which is not approved as medication in respect of a chronic condition; and material for injections Homeopathic Medicines Subject to available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for homeopathic medicines Pharmaceutical Advisory Therapy (P.A.T.) A beneficiary may obtain certain medicines from a pharmacist without a doctor s prescription. Subject to available savings in the member's PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider for such medicines Chronic Medication

23 PMB Conditions Where a PMB condition includes chronic medication, a beneficiary will be entitled to100% of the price specified on the CMRPL of chronic medication, or the lower amount, provided the medication has been approved by the ChroniCare Network Programme and is obtained from a designated service provider. A beneficiary will also be entitled to 100% of the single exit price of that medication and the Scheme Reimbursement Rate (SRR) for the dispensing fee, if it is involuntarily obtained from a provider other than a designated service provider; and the medication is included on the CMRPL; or If voluntarily obtained, the member makes a copayment equal to the difference between the actual cost incurred and the cost that would have been incurred had the drug been obtained from a designated service provider, or where the member had knowingly used a non-reference priced drug.

24 Non-PMB Conditions A beneficiary is entitled to 100% of the price specified on the CMRPL and the Scheme Reimbursement Rate (SRR) for the dispensing fee of chronic medication, for non-pmb chronic conditions as listed in above, subject to an annual limit of R per beneficiary, provided that; the medication has been approved by the ChroniCare Network Programme; and the medication is included on the CMRPL ONCOLOGY (subject to Prescribed Minimum Benefits) Subject to registration with the Oncology Programme, a beneficiary is entitled to % of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of consultations, visits and procedures by general practitioners and medical specialists; % of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of radiotherapy and chemotherapy treatment; and

25 the single exit price of cytostatics used in chemotherapy treatment subject to the CMRPL OPTIC SERVICES Subject to Prescribed Minimum Benefits and available savings in the member s PMSA, a beneficiary is entitled to 100% of the actual amount charged by the provider, for optical services supplied by a registered optometrist, opthalmologist or supplementary optical practitioner for optic examinations or tests, frames, lenses (including contact lenses) and refractive surgery PATHOLOGY Pathology Services Outside Hospital Rate (SRR), or actual cost, if lower, of pathology services rendered by a registered pathologist and medical technologist, outside hospital Pathology Services In Hospital Rate (SRR), or the actual cost, if lower, of pathology services rendered by a registered pathologist and medical technologist, inside hospital.

26 Cancer Screening Tests Rate (SRR), or the actual cost, if lower, of cancer screening pathology tests rendered by a registered pathologist and medical technologist, in or out of hospital RADIOLOGY Radiological Services Outside Hospital A beneficiary is entitled to100% of the Scheme Reimbursement Rate (SRR), or actual cost, if lower, of radiological services and costs of materials outside hospital Radiological Services In Hospital Rate (SRR), or the actual cost, if lower, of radiological services and costs of materials, inside hospital MRIs, CT Scans and Isotope Therapy Subject to pre-authorisation by the Scheme, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of Magnetic Resonance Imaging Scans (MRI Scans), Computerised Axial Tomography Scans (CT

27 27 Scans) and isotope therapy, both in and out of hospital Densitometry Subject to pre-authorisation by the Scheme, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of densitometry limited to one scan per annum Mammograms Subject to pre-authorisation by the Scheme, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of mammograms RENAL DIALYSIS (subject to Prescribed Minimum Benefits) Subject to pre-authorisation and registration with the Renal Disease Management Programme, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of renal dialysis SURGICAL PROSTHESES Subject to pre-authorisation by the Scheme and Prescribed Minimum Benefits, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR) charged by the provider, for internal prosthesis, with a limit of R per beneficiary per annum.

28 TRANSPLANTS Subject to pre-authorisation by the Scheme, a beneficiary is entitled to 100% of the Scheme Reimbursement Rate (SRR), or the actual cost, if lower, of services relating to organ transplants, provided such services are obtained at a designated service provider. Hospitalisation includes harvesting of the organ, post-operative care of member and donor, anti-rejection medicines, professional services in hospital and payment of any other costs relating to the donor, in accordance with the Rules.