SIZWE MEDICAL FUND SIZWE AFFORDABLE OPTION. ANNEXURE B BENEFITS (Effective 1 January 2007)

Transcription

1 SIZWE MEDICAL FUND SIZWE AFFORDABLE OPTION ANNEXURE B BENEFITS (Effective 1 January 2007) A B ENTITLEMENT TO BENEFITS Subject to the provisions of Rule 6 and Rule 12 and to the conditions stipulated in preamble C of this Annexure and paragraph 1 of Annexure C members and their registered dependants are entitled to benefits as stipulated in paragraphs 1 to General The payment of benefits shall be subject to Deleted. 1.2 The provisions of Rule 6.3 and Rule 12 are applicable to all continuation members. The conditions stipulated in preamble C of this Annexure and the conditions in paragraph 1 of Annexure C are applicable to all members. 6.2 The following waiting periods, subject to the provisions of the Act and Rule 8.4: General waiting period 3 months Pre-existing conditions 12 months provided that for all members admitted after 1 July of a financial year the maximum benefits shall be reduced to 50%; provided there shall be no reduction to limits per case. 7. Gap Cover No benefits are available/payable. DEFINITIONS All definitions applicable to this Option are reflected in the Rules

2 - 2 - C CONDITIONS APPLICABLE 1. Where specifically indicated in this Annexure that a member s entitlement to benefits shall be subject to such healthcare management programme the member shall be obliged to furnish any information required by the scheme to perform its duties. Specifically, in the case of the hospital benefit management programme, the scheme may require particulars of diagnosis, clinical investigations, procedures and treatment by the attending medical practitioner of the beneficiary prior to admission of the beneficiary to hospital. 9. In the event that authorisation is not obtained, except in case of an emergency, from the hospital benefit management programme or failure to furnish such information or to grant permission for access to such information as may be required, the member shall make a co-payment of R500 per case. 1. CONSULTATIONS, VISITS, SURGICAL PROCEDURES, NON SURGICAL PROCEDURES AND CONFINEMENTS Subject to the provisions of paragraph 16 and paragraph of Annexure C General practitioners Out of hospital 100% of the NRPL rates for consultations and visits by general practitioners in the suppliers rooms or patient s home or primary healthcare facility with annual limits per member family of Member without dependants R1 500 Member with one dependant R3 000 Member with two dependants R3 500 Member with three dependants R4 000 Member with four dependants R4 400 Member with five dependants R4 800 Member with six or more dependants R5 200

3 Specialist Services Out of hospital 100% of the NRPL rates for consultations and visits by medical specialists, excluding Psychiatrists, in the suppliers rooms or patients home or primary healthcare facility with annual limits per member family of - Member without dependants R1 050 Member with one dependant R1 900 Member with two dependants R2 350 Member with three dependants R2 550 Member with four dependants R2 850 Member with five dependants R3 050 Member with six or more dependants R SURGICAL PROCEDURES 2.1 Out of Hospital General Practitioners 100% of the NRPL rates for consultations and visits by General Practitioners in the supplier s rooms or patients homes. Subject to no limit per beneficiary and within the limits as stipulated in paragraph Medical Specialists 100% of the NRPL rates for consultations and visits by Medical Specialists in the supplier s rooms or patient s homes. Subject to the limit stipulated in paragraph In Hospital Subject to the Hospital Benefit Management Programme General Practitioners 100% of the NRPL rates for consultations and visits by General Practitioners in Hospital.

4 Medical Specialists 100% of the lower of the NPRL rates for consultations and visits by Medical Specialists in Hospital. 10 NON-SURGICAL PROCEDURES 100% of the NPRL rates for all non-surgical procedures performed by a General Practitioner or Medical Specialist. Subject to limits stipulated in paragraph and respectively. 4. DENTISTRY Dentistry benefits are subject to the Dental Benefit Management program. No financial restrictions apply; benefits are only limited by clinical protocols and restrictions. (The description of dental benefits is also reflected in your benefit brochure) Conservative dentistry 100% of the Sizwe rates subject to the following conditions. Consultations and Oral Hygiene ) Extractions and Fillings ) refer to protocols Root Canal Treatment ) 11.2 Special dentistry 100% Sizwe rates subject to no limit in respect of the following benefits: A 20% benefit reduction is applied for late pre-authorisation except in the case of emergency hospital admission also applicable to orthodontics.. Crowns & bridges 1 crown per family per year Surgical periodontics no benefits are available/payable Implants no benefits are available/payable Surgery clinical restriction/s Surgical periodontics no benefits are available/payable

5 Orthodontics 100% of the Sizwe rates. Orthodontic treatment is subject to pre-authorisation and restricted to beneficiaries under the age of 18 years. 4.4 Dental Hospitalisation Dental Hospitalisation Benefits subject to Pre-authorisation, Hospital Benefit Management Programme and Dental Benefit Management Programme. No limit is applicable. 9.4 Dentures 100% of Sizwe rates. The benefits are subject to the following limits- One plastic denture per jaw every 4 years and one metal frame denture every 5 years, commencing from the date the beneficiary obtains his/her first denture. 5. MATERNITY 5.1 Hospitalisation (Public or private hospitals) Subject to the hospital benefit management programme and to the disease management programme 100% of the NRPL rates for accommodation at general ward rates, theatre fees, labour ward fees, drugs, dressings, medicines and materials in a private or provincial hospital and 100% of the NRPL rates for drugs, dressings, medicines and materials supplied by a midwife. 5.2 Medical services and midwifery Subject to the conditions and limits as stipulated hereunder Ante-natal consultations 100% of the NRPL rates for ante-natal consultations Pregnancy scans and tests 100% of the NRPL rates for pregnancy scans and other pregnancy related tests.

6 Delivery 100% of the NRPL rates for the delivery by a general practitioner, medical specialist or midwife and materials supplied Post-natal services and midwifery Subject to the hospital benefit management programme and to the disease management programme - 100% of the NRPL rates for post natal care by a midwife or as an alternative to hospitalisation The benefits in paragraph 5.2 are subject to the annual limits set out in paragraphs and respectively. 12. INFERTILITY All treatment for an infertility condition will only be covered in the public sector and in accordance with the policies of the relevant Public Authorities. 13. MEDICINE AND INJECTION MATERIAL 7.1 Acute sickness conditions Subject to the conditions and limits stipulated in paragraph Legally prescribed 100% of the cost of medicines and injection material prescribed by a person legally entitled to prescribe: provided that where there is a generic equivalent the benefit shall not exceed the maximum retail price of the generic equivalent. This paragraph excludes prescriptions supplied for use in a hospital but includes all medicines given to a patient to take home Pharmacy advised therapy 100% of the cost of medicines advised and dispensed by a pharmacist and for which a script is provided, subject to the acute medicine limit as stipulated in paragraph There is no limit per script and no levy payable at point of sale.

7 Chronic sickness conditions Medicines other than anti-retroviral medicines. Subject to approval and acceptance on the chronic medication programme and the conditions and limits stipulated in paragraph % of the cost of registered medicines and injection material prescribed by a person legally entitled to prescribe: provided that where medication prescribed is not authorised, the benefit shall be at 100% of the cost and subject to and charged against the limits in paragraph subject to PMBs 13.2 Annual Limits Acute Medicines The benefits under paragraph 7.1 have annual limits per member family of - Member without dependants R2 550 Member with one dependant R3 850 Member with two dependants R4 600 Member with three dependants R4 950 Member with four dependants R5 700 Member with five dependants R5 850 Member with six or more dependants R6 000 There is no levy payable at point of sale Chronic Medicines for the conditions as reflected in the disease list subject to approval The benefits under paragraph 7.2 have annual limits of 100% of cost for PMB conditions through a designated service provider

8 % of tariff Member without dependants R Member with one dependant R Member with two dependants R Member with three dependants R Member with four dependants R Member with five dependants R Member with six or more dependants R Subject to a maximum of R3 400 per beneficiary. There is no levy payable at point of sale. 14. ONCOLOGY Prescribed Minimum Benefits subject to Pre-authorisation, Minimum Benefit Package, Designated Service Providers and Treatment Protocols. Oncology Benefits subject to Pre-authorisation and Treatment Protocols 100% of the NRPL rates for consultations, visits and treatment, and 100% of costs for medication and materials used in radiotherapy and chemotherapy and subject to an annual limit of R per family subject to PMBs. 15. HOSPITALISATION Prescribed Minimum Benefits subject to Pre-authorisation, Minimum Benefit Package, Designated Service Providers and Treatment Protocols Hospitalisation Benefits subject to Pre-authorisation, Hospital Benefit Management Program and Disease Management Programme Private and public hospitals, registered unattached operating theatres and day clinics in-patient care Subject to the conditions and limits as stipulated in paragraph 9.4. Psychiatry hospitalisation is limited to 21 days per beneficiary per annum including psychiatrist consultations and six in hospital consultation by clinical psychologist subject to PMBs.

9 - 9 - Admissions are subject to pre-authorisation % of the NRPL rates for accommodation in a general ward, high care ward and intensive care unit % of the NRPL rates for theatre fees % of the NRPL rates for medicines, materials and hospital equipment and the transport of blood Medicines for the patient to take home as stipulated in paragraph Private and public hospitals out-patient care Subject to the conditions and limits as stipulated in paragraph % of the NRPL rates for out patient services, materials and medicines at tariff Medicines given to a patient to take home as stipulated in paragraph Alternatives to hospitalisation Subject to the hospital benefit management programme, disease management programme and the conditions and limits stipulated in paragraph % of the NRPL rates for all service rendered by registered step down nursing facilities, hospice and rehabilitation centres. 2.1 Annual Limits Private Hospitals Benefits set out in paragraphs 9.1 and 9.2 have no limits per annum. No specific clinical exclusions are applicable.

10 Alternatives to Hospitalisation Prescribed Minimum Benefits subject to Pre-authorisation, Minimum Benefit Package, Designated Service Providers and Treatment Protocols Hospitalisation Benefits subject to Pre-authorisation and the Hospital Benefit Management Program Subject to 100% of NRPL rates and an annual limit of R4 200 per family Public Hospitals Prescribed Minimum Benefits subject to Pre-authorisation, Minimum Benefit Package, Designated Service Providers and Treatment Protocols Hospitalisation Benefits subject to Pre-authorisation and the Hospital Benefit Management Program Subject to 100% cost rates within the limit stipulated in paragraph 9.4. No limit on prescribed minimum benefits, as stipulated in paragraph AUXILIARY AND OTHER SERVICES 10.1 Auxiliary services Audiology, Chiropractics, Dietetics, Educational Psychologist and Social Workers, Homeopathy, Occupational Therapy, Podiatry, Speech Therapy, Orthoptic Treatment and Physiotherapy(Out of Hospital). 100% of the NRPL rates with the following annual limits per family: Member R 900 Member with one or more dependants R Deleted

11 Appliances (excluding prostheses provided for in paragraph 10.10) 100% of cost with the following annual limits per family: Member without dependants R 875 Member with one or more dependants R Private Nursing : subject to Hospital Benefit Management Programme 100% of NRPL rates with the following annual limits per family Member without dependants R 875 Member with one and more dependants R Ambulance services 100% of the cost of ambulance services rendered by a preferred provider - subject to pre-authorisation. If services are not pre-authorised through the preferred provider, claims will not qualify for payment Blood transfusions and blood replacement products 100% of the cost of blood transfusions and blood replacement products subject to an annual limited to R per family subject to PMBs Clinical and medical technologists For services rendered and material and apparatus supplied Clinical technologists 100% of the NRPL rates within the following annual limits per family Member without dependants R 900 Member with one or more dependants R Medical technologists 100% of the NRPL rates subject to the limit as stipulated in paragraph

12 Physiotherapy In Hospital 100% of the NRPL rates whilst hospitalised. Out of Hospital Benefits are included and payable within the annual limit of the Auxiliary benefits as stipulated in paragraph Prosthesis and Cardiac Stents Prosthesis Benefits subject to pre-authorisation and subject to PMBs Surgical and non surgical 100% of the cost of prostheses subject to: - annual limit of R per family Cardiac stents - 100% of cost of 3 cardiac stents per family per annum Hearing Aids 100% of the NRPL rates, subject to an annual limit of R5 000 per family. One hearing unit per beneficiary every 2 years from date of acquisition Mental Health (Psychiatry, Psychology excluding Educational Psychology and Social Workers) 100% of the NRPL rates subject to an annual limit of R5 250 per family subject to PMBs. 9. OPTICAL One set of Spectacle Lenses and one set of Frames, or one set of Contact Lenses, per beneficiary every two years Each beneficiary must choose either spectacles or contact lenses once every two years

13 Spectacles, lenses and frames combined limit % of the SAOPTA rates determined by the Board of Trustees for spectacles and lenses prescribed or supplied by a registered optometrist, ophthalmologist or supplementary optical practitioner. Provided that: The benefit for a visual examination, if undertaken by a registered optometrist or ophthalmologist, shall be based on the SAOPTA rates. The benefit shall be 100% of the SAOPTA rate and shall be limited to one eye test per beneficiary per 24 month period The benefit for frames be limited to one pair per beneficiary per 24 month period to a limit to the combined benefit and any difference, if applicable, is payable by the member directly to the supplier The benefit is limited to one pair of spectacles per beneficiary per 24 month period, except where two spectacles are approved by the Fund in place of a pair of spectacles with bifocal or multi focal lenses, after clinical motivation by a registered optometrist or ophthalmologist to the Fund The benefit is limited to the approved tariff for glass photo chromic lenses and glass or organic lenses with a tint not exceeding 35% The benefit for bifocal or multi focal lenses shall be limited to the cost of 65 millimetre bifocal lenses with a read segment of 28 millimetre All add-ons considered as clinical essential (indicator codes 1 to 4) shall be paid by the Fund.

14 All add-ons considered as exclusions or optional (indicator codes 5 to 9) except those as mentioned in the Rules be excluded from benefits except if prior approval from the Fund was given on clinical and/or medical ground as motivated by a registered optometrist or ophthalmologist Each claim for lenses/frames must be submitted together with the lens prescription Sunglasses and repairs to spectacles are excluded from benefits Benefits shall not be granted for spectacles if a beneficiary has already received a benefit for contact lenses in a given 24 month period Contact lenses % of the cost of clear contact lenses if prescribed by a registered optometrist, ophthalmologist or supplementary optical practitioner in accordance with the approved tariff for these service providers. Provided that: The application by a member be motivated by a recommendation from a registered optometrist or ophthalmologist that contact lenses are clinically essential as determined by the lens prescription on clinical/medical grounds and approved by the Fund The benefit is limited to one pair of permanent contact lenses per beneficiary per 24 month period, or 26 pairs of bi-weekly disposable lenses per beneficiary per annum, or 12 pairs of monthly disposable contact lenses per beneficiary per annum. Additional benefits may be approved on medical/clinical grounds if approved by the Fund In cases where contact lenses are not clinically essential the benefit shall be limited to the equivalent of two single vision glass lenses of 65mm and a sphere of 2 dioptres plus the benefit amount of the frame, plus the cost of a refraction, as a combined benefit Benefits shall not be granted for contact lenses if a beneficiary has already received a pair of spectacles in a given 24 month period Contact lens cleaning materials are excluded from benefits.

15 Spectacle Lenses & Frames combined limit The benefits under paragraph 11.1 have annual limits per member family of 100% SAOPTA rates Member without dependants R1 500 Member with one dependant R1 675 Member with two dependants R1 850 Member with three dependants R2 000 Member with four dependants R2 050 Member with five dependants R2 100 Member with six or more dependants R Frames 100% of cost included in the combined limit Multi focal Lenses benefit limited to R500 per lens subject to annual limit in paragraph Lens additions - subject to annual limit in paragraph Sunglasses no benefits are available/payable Repairs to frames and lenses no benefits are available/payable. 10. RADIOLOGY AND RADIOGRAPHY Subject to the conditions as reflected hereunder, excluding paragraph 12.2, which has a separate limit General Out of hospital 100% of the NRPL rates for general diagnostic radiology benefit is payable within R2 550 annual limit per family In hospital Subject to the Hospital Benefit Management Programme and to the Disease Management Programme. 100% of the NRPL rates for general diagnostic radiology whilst hospitalised. 9.5 Specialised Radiology MRI/CAT Scans/Angiograms are limited, as stipulated hereunder Out hospital 100% of the NRPL rates for MRI/CAT Scans/Angiograms, combined with in-hospital specialised radiology benefit.

16 13. PATHOLOGY SIZWE AFFORDABLE OPTION In hospital Subject to the Hospital Benefit Management Programme and to the Disease Management Programme. 100% of the NRPL rates for MRI/CAT Scans/ Angiograms subject to an annual limit of R per annum per family. Subject to the conditions and annual limits, as reflected hereunder: 13.1 Out hospital 100% of the NRPL rates for tests performed by a general practitioner, medical specialist or medical technician and private nurse practitioner. Annual limit of R2 450 per family In hospital Subject to the Hospital Benefit Management Programme and to the Disease Management Programme. 100% of the NRPL rates for tests performed by a general practitioner or medical specialist whilst hospitalised. Pathology tests required for acquired immune deficiency syndrome fall within the limit as stipulated in paragraph ASSOCIATED HEALTH SERVICES 14.1 Chiropractic treatment Benefits are payable under the conditions stipulated in paragraph Homeopathy Benefits are payable under the conditions stipulated in paragraph Medicines, prescribed and dispensed fall within the benefit limit as stipulated in paragraph

17 LIMITATIONS ON SPECIFIED TREATMENT AND SICKNESS CONDITIONS Notwithstanding the provisions of paragraphs 1 to 15 the benefit for services provided in terms of the Rules in respect of the under noted specified treatment or sickness conditions will (unless stipulated otherwise below) be given at the percentage stipulated in the relevant paragraphs of the lower of the cost or the NRPL rates subject to the limitations set down in the relevant paragraphs below: 9.4 Refractive surgery including Radial Keratotomy No benefits are available/payable subject to PMBs. 9.5 Alcoholism, drug addiction, narcotism Prescribed Minimum Benefits subject to Pre-authorisation, Minimum Benefit Package, Designated Service Providers and Treatment Protocols 3 days withdrawal treatment at an appropriate facility. 9.6 Acquired immune deficiency syndrome (HIV/AIDS) The HIV/Aids as a PMB benefit is provided via a DSP facility provider. No annual limit is applicable and benefits are subject to participation in a Preferred Provider Disease Management Programme and Disease Management Programme. Benefits include counselling, prescribed medication, pathology tests and relevant consultations. 9.7 Organ Transplants and Renal Dialysis Prescribed Minimum Benefits subject to Pre-authorisation, Minimum Benefit Package, Designated Service Providers and Treatment Protocols The Organ Transplant benefit is restricted to Public Hospitals and is subject to Pre-authorisation and Treatment Protocols The Renal Dialysis benefit is restricted to the requirements set out in the Prescribed Minimum Benefits

18 Subject to the hospital benefit management programme % of the NRPL rates of organ or transplantation thereof and cost of post operative anti-rejection medicines required by the recipient Annual limit of R per family subject to PMBs. 9. BENEFITS AND PAYMENT OF PRESCRIBED MINIMUM BENEFIT (PMB) 9.4 Prescribed Minimum Benefits (PMB) PMB are not subject to annual benefit limits, except for such limits as may be prescribed in terms of the regulations. Benefits provided in terms of paragraphs 1 15 falling outside the scope of PMB have annual limits as stipulated Subject to Rule 15.5 PMB shall be payable at 100% of cost in Public facilities as determined from time to time. Any lesser percentage stipulated in this Annexure shall apply to benefits falling outside the scope of PMB. 9.4 Subject to Rule 15.5 PMB shall cover the cost of all relevant health services included in the comprehensive fee of public hospitals The following chronic conditions will also be covered in terms of PMBs at DSPs. Addison s disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac failure Cardiomyopathy Chronic obstructive pulmonary disease Chronic renal disease Coronary artery disease Crohn s disease Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple sclerosis Parkinson s disease Rheumatoid arthritis Schizophrenia

19 Diabetes insipidus Diabetes mellitus types 1 & 2 Dysrhythmias Systemic lupus erythematosus Ulcerative colitis HIV/AIDS -----o0o-----