How the scheme works

Transcription

1 Maxima Range Maxima Standard Net B E N E F I T S R I S K Major Medical Benefit Chronic Disease Benefit Safety Net Benefit Savings OHEB B E N E FI T S D A Y -T O D A Y -T O B E N E FI - D A Y - D A Y How the scheme works Major Medical Benefit All costs for hospitalisation are covered from this benefit at network hospitals and must be pre-authorised. Chronic Disease Benefit Medication for approved chronic diseases is covered from this benefit. Benefit The Benefit pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have been accumulated to the required level. Day-to-Day Benefit Day-to-day expenses are covered from Savings and the Out-of-Hospital Expenses Benefit (OHEB). FEDHEALTH membership means REAL Medical Aid, REAL Service and REAL Benefits. Introducing Maxima Standard Net, a Comprehensive Option. Maxima Standard Net provides young and healthy families with unlimited hospitalisation at Network Hospitals and funds Day-to-Day claims for medical consultations and over-the-counter medication first from a Savings Account, and then from the Out-of-Hospital Expenses Benefit. It also features unlimited cover at cost for Fedhealth Network specialists in-hospital. The option then also goes the extra mile to provide extensive cover for 39 chronic conditions. It also adds value further still with a Benefit and seriously enhanced Risk benefits, like unlimited visits to Network GPs. contributions Rand amounts paid monthly to the Scheme for cover received as well as annual benefit values healthcare spending Examples of healthcare spend available for various family structures, as well as Savings * Up to a maximum of three children Risk Savings TOTAL annual threshold levels and self-payment gaps OHEB Dayto-Day * Level OHEB Member Adult Dependant Child Dependant Self- Payment Gap M M + AD M + AD + CD M - member AD - adult dependant CD - child dependant

2 comprehensive option Maxima Standard Net Overall annual limit (OAL) major medical benefit All costs for hospitalisation are covered from this benefit at network hospitals and must be pre-authorised Healthcare Professional Tariff (HPT) - Fedhealth Network GPs and Specialists - Non-Fedhealth Network GPs ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Unlimited at network hospitals only Covered at cost Covered at 100% of FR major medical benefit (continued) Emergency treatment in a casualty ward Female health benefit: contraceptives Immune deficiency related to HIV infection Oncology ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Unlimited at FR Unlimited at MPL Unlimited (See HPT above) R Subject to Standard Protocols. DSP-ICON above limit (See HPT above) [ 1 - Non-Fedhealth Network Specialists Covered at 100% of FR - Other Healthcare Professionals Covered at 200% of FR Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals Hospitalisation costs Unlimited at negotiated tariff at network hospitals only. R5 000 co-payment on voluntary use of non-network hospitals Co-payments See details on page 2 Alternatives to hospitalisation - Sub-acute facilities and physical rehabilitation facilities - Nursing services, private nurse practitioners & nursing agencies Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Maxillo-facial surgery Incl surgical extraction of impacted wisdom teeth PMB level of care only Unlimited at negotiated tariff Unlimited with Europ Assistance Unlimited at cost Unlimited (See HPT above) Unlimited, subject to approval (See HPT above) Co-payment applies to surgical extraction of impacted wisdom teeth - Specialised medication Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Post-hospitalisation benefit Post-natal midwifery benefit Prostheses - Internal - External Psychiatric services Renal Dialysis (chronic) No benefit R (See HPT above) R per beneficiary Unlimited at FR Up to 30 days after discharge at FR 4 consultations per pregnancy at FR Various sub-limits apply (See page 4) R9 970 R (See HPT above) - Haemodialysis and peritoneal dialysis R at FR Specialised medication benefit (eg. biologicals) - oncology & non-oncology No benefit Specialised radiology Unlimited at FR Take-out medicines 7 days medication per hospital event at MPL Terminal care benefit R at FR FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff DSP - Designated Service Provider MPL - Medicine Price List

3 [ 2 PROCEDURE co-payments CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY Colonoscopy, Upper GI endoscopy R2 500 Surgical extraction of impacted wisdom teeth R3 360 Open hiatus hernia surgery R3 360 Rhizotomies and facet pain block (limited to 1 of either procedures per beneficiary per year) R3 600 Balloon sinuplasty R5 930 Spinal surgery No co-payment Joint replacements R6 720 Arthroscopic procedures Ankle, Knee, Shoulder R2 500 Hip, Wrist theatre fees, anaesthetist & surgeon will be covered Laparoscopic procedures Appendectomy, Hernia repairs (other than inguinal hernia repair) theatre fees, anaesthetist & surgeon will be covered Diagnostic, Nissen/ Toupey R2 500 Nephrectomy theatre fees, anaesthetist & surgeon will be covered All arthroscopic and laparoscopic procedures not listed above theatre fees, anaesthetist & surgeon will be covered screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health Women s Health Breast cancer screening with mammography Cervical cancer screening (PAP smear - test only) Liquid based Cytology will be reimbursed up to the rate for a standard PAP smear CRITERIA Women; ages 50 to 74 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme As per State EPI As per State EPI Cardiac Health Cholesterol screening (full lipogram) All lives; aged 20 years and older 1 every 5 years Geriatric Health Pneumococcal vaccination Bone densitometry Colorectal cancer screening (faecal occult blood test) All lives; older than 65 Women; older than 65 All lives; ages 50 to 75 No benefit General Flu vaccination All lives 1 every year EPI - Expanded Programme on Immunisation

4 [ 3 network hospitals HOSPITAL PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Life Mercantile Hospital Eastern Cape Korsten Life St George s Hospital Eastern Cape Centrahill Life St James Hospital Eastern Cape Southernwood Horizon Eye Care Centre Free State Bloemfontein Life Pasteur Hospital Free State Bloemfontein Life Rosepark Hospital Free State Bloemfontein Netcare Bougainville Hospital Gauteng Hercules Life Brenthurst Clinic Gauteng Johannesburg Cormed Clinic Gauteng Vanderbijlpark Life Dalview Clinic Gauteng Brakpan Life Flora Clinic Gauteng Roodepoort Life Fourways Hospital Gauteng Fourways Gardens Life The Glynnwood Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Central Midvaal Private Hospital Gauteng Three Rivers HOSPITAL PROVINCE SUBURB Life Robinson Private Hospital Gauteng Randfontein Life Roseacres Clinic Gauteng Primrose Life Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Durdoc Clinic Kwa-Zulu Natal Durban Central Life Entabeni Hospital Kwa-Zulu Natal Durban Maxwell Clinic Kwa-Zulu Natal Qualbert Life Mount Edgecombe Hospital Kwa-Zulu Natal Mount Edgecombe Life Westville Hospital Kwa-Zulu Natal Westville Netcare Blaauwberg Hospital Western Cape Bloubergrant Mediclinic Cape Gate Western Cape Cape Gate Mediclinic Cape Town Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Life Claremont Hospital Western Cape Claremont Life Kingsbury Hospital Western Cape Claremont Life West Coast Private Hospital Western Cape Vredenburg Please note that this list may change/ expand during the year. Please contact the Fedhealth Customer Contact Centre on or refer to the website for the latest Maxima Standard Net Network Hospital list

5 internal prosthesis benefit table This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Detachable platinum coils R Cardiac stents R Cardiac valves R Cardiac pacemakers R Aorta stent grafts R Intraocular lenses (per lens) R2 804 Shoulder replacement R Elbow replacement R Hip replacement R Knee replacement R Total ankle replacement Bone lengthening devices Spinal plates and screws Carotid stents See combined benefit limit for all unlisted internal prosthesis* Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices Combined benefit for all unlisted internal prosthesis *R Limit Conditions covered Formulary Designated Service Provider (DSP) Formulary Designated Service Provider (DSP) Limit chronic disease benefit Medication for approved chronic diseases is covered from this benefit IN- (Lists 1 and 2) OUT-OF- (List 1 below only) R4 860 per beneficiary, subject to an overall limit of R9 670 per family per year 39 conditions See lists 1 & 2 below Comprehensive formulary Service provider of choice Restrictive formulary Medi-Rite pharmacy HIV/ AIDS MEDICINE INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Unlimited In-benefit means that you have not exhausted your Chronic Disease Benefit limit. Out-of-benefit means that you have exhausted your Chronic Disease Benefit limit. Non-compliance with DSP and/ or formulary requirements, will attract a co-payment of 40%. If this is in respect of a PMB condition, then the co-payment is not refundable from Savings. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. CHRONIC CONDITIONS LISTS LIST 1. PMB Conditions: Addison s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, COPD/ Emphysema/ Chronic Bronchitis, Chronic Renal Disease, Coronary Artery Disease, Crohn s Disease, Diabetes Insipidus, Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis [ 4 LIST 2. Additional chronic conditions covered on Maxima StandardNet: Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Bulimia Nervosa, Depression, Dermatomyositis, Generalised Anxiety Disorder, Narcolepsy, Obsessive Compulsive Disorder, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Post-Traumatic Stress Syndrome, Scleroderma, Tourette s Syndrome

6 day-to-day benefit Day-to-day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses Benefit (OHEB) and carry over Savings. Limits may apply when calculating certain claims for accumulation to. These limits will also apply for refunds from OHEB and Co-payments in Appliances, external accessories and orthotics Alternative healthcare 20% co-payment R per family per year before and after. (R3 710 sub-limit for foot orthotics). Maternity Optometry day-to-day benefit (continued) Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations [ 5 2 x 2D antenatal scans per year before and after. R2 860 per beneficiary per year, R8 700 per family per year before and after. Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Subject to Savings and OHEB. Does not accumulate to or pay from Over-the-counter medication Subject to Savings only. Does not accumulate to or pay from Additional medical services Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy Dentistry (Advanced) Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment R per family per year before and after. R6 390 per beneficiary per year, R per family per year before and after. Prescribed medication Radiology (Specialised) Specialists excluding psychiatrists - Fedhealth Network Specialists R8 520 per beneficiary per year, R per family per year before and after. Paid from the Major Medical Benefit if pre-authorised accumulation at cost to. Unlimited at cost once is reached Biokinetics, Chiropractics, Dentistry (Basic), Radiology (General), Pathology and Physiotherapy General Practitioners - Fedhealth Network GPs. Unlimited once is reached Subject to OHEB then unlimited from Risk - Non-Fedhealth Network Specialists. Unlimited accumulation to and refund from at FR - Non-Fedhealth Network GPs. Unlimited accumulation to and refund from at FR FR - Fedhealth Rate OHEB - Out-of-Hospital Expenses Benefit

7 Specialists: Psychiatrists - Fedhealth Network Psychiatrists - Non-Fedhealth Network Psychiatrists day-to-day benefit (continued) THRESHOLD Subject to Additional Medical Services limit of R per family per year before and after. Subject to Savings, OHEB and accumulation at cost to Subject to Additional Medical Services limit of R per family per year before and after. Subject to Savings, OHEB and. Accumulation to and refund from at FR only The Benefit pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have accumulated up to the required level. The Level is reached through the accumulation of claims paid from Savings, OHEB and the member s own pocket through the year at the Fedhealth Rate, unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from. A 20% co-payment will apply to all claims paid from the Benefit on Maxima Standard Net. No co-payment will apply to GP or specialist consultations in-network. Benefits that set us apart We offer unique value-added benefits. With these benefits we ensure that members day-to-day spending not only goes further, but also works harder when they need it to. Benefits unique to Fedhealth: Unlimited Network GP visits paid from Risk and never from Savings Child rates for financially dependent children up to 27 years of age Upgrades to higher options any time of the year within 30 days of diagnosis of a dread disease, or in the case of a life changing event. *New contributions will apply Where we pay more from Risk than other schemes: Post-hospitalisation treatment for up to 30 days after discharge from hospital is paid directly from Risk, so as not to deplete members day-to-day benefits 7 days of paid for take-home medication after discharge from hospital paid from Risk Specialised radiology like MRI and CT scans - paid from Risk and never from Savings - whether performed in or out-ofhospital Trauma treatment at a casualty ward - whether admitted or not, emergency treatment is always paid from Risk Cover for female contraception *must be prescribed by a GP or gynaecologist and not applicable to pills prescribed for acne The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk. How we add value: The Fedhealth Baby Programme 24-Hour Fedhealth Nurseline FREE trauma counselling for practical and emotional support Emergency transport/ response through Europ Assistance Comprehensive managed care programmes: ~ Aid for AIDS (AfA) ~ AsthmaCare ~ DiabeticCare ~ CardioCare ~ Oncology Disease Management. And then members still get: Professional and extreme sports cover - injuries sustained during sporting activities are covered In-hospital dentistry for children under 8 - hospital and anaesthetist costs covered from the In-Hospital Benefit, while the dentist s account comes from day-to-day benefits. *The Authorisation Centre must be contacted at least 48 hours before the procedure Easy membership for former child dependants - meaning no underwriting required for former child dependants. Scheme rules & conditions apply. [ 7 Disclaimer: This document is a summary for information purposes only and does not supersede the rules of the Scheme. In the event of any discrepancy between this summary and the Rules, the Rules will prevail. A copy of the Rules is available on request.