PLUS PLAN SUMMARY OF BENEFIT AND CONTRIBUTION CHANGES FOR 2016

Transcription

1 PLUS PLAN SUMMARY OF BENEFIT AND CONTRIBUTION S FOR 2016 Contributions on the Plus Plan for 2016 will increase by approximately 9.5 across all family sizes (Bankmed average: 7.8). Please also note that the savings allowance included in the overall contributions for the Plus Plan will increase by 5, which is lower than the total contribution increase catered for on this plan. Please refer to the enclosed 2016 Benefit and Contribution Schedule to calculate your total monthly contribution for A contribution calculator is also available on our website at Rand limit and other changes are provided in a summarised format in the tables below. Please refer to the 2016 Benefit and Contribution Schedule for detailed rates of cover and any other arrangements that may apply to the benefits/services listed. The numbering in this summary corresponds to the numbering in the 2016 Benefit and Contribution Schedule. PLUS PLAN: RAND LIMIT S EFFECTIVE 1 JANUARY Wellness and preventative R240 pbpa R250 pbpa 4.16 care (insured) benefits: Cholesterol screening, blood sugar screening and blood pressure measurements 3.14 Pap smear consultation R375 pbpa R395 pbpa Personal Health Assessment R575 pbpa R605 pbpa 5.21 (PHA) 3.16 Contraception: R1 500 per female beneficiary per annum R1 575 per female beneficiary per annum 5 Oral contraceptives, devices and injectables 14.4 Pregnancy and childbirth Birthing facilities as an alternative to hospitalisation Cost of disposables R855 per case R900 per case 5.26 /S 1

2 PLUS PLAN: RAND LIMIT S EFFECTIVE 1 JANUARY 2016 (CONTINUED) 16.3 Alternatives to hospitalisation: R355 pb per day R375 pb per day 5.33 Frail care facilities 16.4 Home nursing R270 pb per day R285 pb per day Internal prosthesis: R pbpa R pbpa 5 Combined limit for all internal prosthesis items, excluding pacemakers and defibrillators 17.2 Internal prosthesis sub-limits (subject to combined limit for all internal prosthesis items): Partial hip replacement R R Total hip replacement R R Total knee replacement R R Shoulder replacement R R Spinal fusions R R Cardiac stents R R Grafts R R Cardiac valves R R Non-specified items R R Cochlear implants: R pb per lifetime Pre-operative evaluation and associated preparation costs 19.3 Cochlear implant device R pb per lifetime R pb per lifetime Intra-operative audiology R715 pb per lifetime testing 19.5 Post-operative evaluation costs R pb per lifetime 20.1 Speech processors: R pb over a five-year cycle R pb over a five-year cycle 5 Upgrade or replacement of speech processors 21.1 Hearing aids: R pb every second year R pb every second year 5.11 Supply and fitment 21.2 Hearing aid repairs 100 of cost, limited to R1 130 pbpa 100 of cost, limited to R1 190 pbpa Bone anchored hearing aids 90 of cost, limited to R pfpa 90 of cost, limited to R pfpa 5 /S Cost split provided for clarification 5 increase on 2015 benefit allocation 2

3 PLUS PLAN: RAND LIMIT S EFFECTIVE 1 JANUARY 2016 (CONTINUED) 22.1 External prosthesis: Benefit for limbs and eyes 22.2 Medical and surgical appliances Post-surgery appliances Medical and surgical appliances Chronic appliances R pfpa R pfpa 5 R5 460 pbpa R5 750 pbpa 5.31 R pbpa for oxygen/oxygen delivery systems R pbpa for stoma products R pbpa for oxygen/oxygen delivery systems R pbpa for stoma products /S R5 460 pbpa for other chronic appliances, including wheelchairs R5 750 pbpa for other chronic appliances, including wheelchairs 5.31 Medical and surgical appliances Appliances for acute conditions (Other chronic appliances limit extended to R8 000 for beneficiaries requiring a CPAP machine) Subject to limit for other chronic appliances of R5 460 pbpa (Other chronic appliances limit extended to R8 400 for beneficiaries requiring a CPAP machine) Subject to limit for other chronic appliances of R5 750 pbpa Blood pressure monitors, nebulisers and glucometers (subject to combined limit for other chronic appliances) Blood pressure monitors: R920 pbpa Nebulisers: R1 295 pbpa Glucometers: R650 pbpa Blood pressure monitors: R970 pbpa Nebulisers: R1 360 pbpa Glucometers: R685 pbpa 23.1 Psychiatry, clinical psychology and related occupational therapy: Hospitalisation and in-hospital consultations/sessions R pbpa R pbpa Occupational therapy: Psychiatric consultations/sessions in hospital Combined limit Combined limit 36.5 Medicine: Chronic medication R pbpa R pbpa

4 ANNUAL THRESHOLD AND ABOVE THRESHOLD BENEFIT 37.2 Annual threshold (accumulation) Above Threshold Benefit (ATB) PLUS PLAN: S TO THE ANNUAL THRESHOLD AND ABOVE THRESHOLD BENEFITS FROM 1 JANUARY Combined annual threshold of R for the principal member R9 500 per adult dependant R3 100 per child dependant (limited to three children) Combined ATB of Combined annual threshold of R for the principal member R per adult dependant R3 400 per child dependant (limited to three children) Combined ATB of /S R for the principal member R9 500 per adult dependant R3 100 per child dependant (but limited to three children) R for the principal member R per adult dependant R3 300 per child dependant (but limited to three children)

5 PLUS PLAN: S TO LIMITS ON ACCUMULATION TOWARDS ANNUAL THRESHOLD AND/OR PAYMENT OF INSURED ATBs EFFECTIVE 1 JANUARY 2016 Benefits listed in this section are payable from savings, with accumulation towards the annual threshold at 100 of the Scheme rate (or Bankmed Network rate) Payment from insured ATBs only applies once the annual threshold has been reached BENEFIT/SERVICE 15.4 Radiology and pathology 23.2 Psychiatry, clinical psychology and related occupational therapy: Consultations/sessions out of 2015 LIMIT ON ACCUMULATION TOWARDS THRESHOLD AND/OR PAYMENT OF ATB 2016 LIMIT ON ACCUMULATION TOWARDS THRESHOLD AND/OR PAYMENT OF ATB /S R4 795 pfpa R5 035 pfpa 5 hospital R pfpa R pfpa Occupational therapy: Psychiatric consultations/sessions 24.4 Non-psychiatric consultations/sessions 25.1 Speech therapy, audio therapy and audiology (in and out of hospital) 26.2 Physiotherapy: Posthospitalisation physiotherapy within six weeks of discharge from hospital following an R5 645 pfpa R5 950 pfpa 5.4 R1 695 pfpa R1 780 pfpa 5 authorised hospital admission R2 260 pbpa R2 375 pbpa Physiotherapy 5

6 PLUS PLAN: S TO LIMITS ON ACCUMULATION TOWARDS ANNUAL THRESHOLD AND/OR PAYMENT OF INSURED ATBs EFFECTOVE 1 JANUARY 2016 (CONTINUED) BENEFIT/SERVICE LIMIT ON ACCUMULATION TOWARDS LIMIT ON ACCUMULATION TOWARDS THRESHOLD AND/OR PAYMENT OF ATB THRESHOLD AND/OR PAYMENT OF ATB /S 28.1 Other auxiliary services (in and out of hospital): Chiropody, podiatry, dietetics (nutritional assessments), orthotics, massage, chiropractors, herbalists, naturopaths, family planning clinics, homeopaths and biokineticists (fitness assessments) 30.1 Dentistry and orthodontics: Preventative and basic dentistry 30.2 Advanced dentistry (caps, crowns, bridges and cost of endosteal and osseaintegrated implants) 30.3 Orthodontics (subject to orthodontic quotation and prior approval from Scheme) 30.4 All other dental services 34.1 Optometry: Consultations 34.3 Prescription lenses and readymade readers 34.4 Contact lenses 34.5 Fitting of contact lenses 35.1 Refractive surgery and associated costs: Other optometric services (refractive surgery/excimer laser treatment, hospitalisation and associated costs) 36.2 Medicine: Prescribed acute medication R2 400 pfpa R2 520 pfpa 5 R for a single member R for a family R for a single member R for a family R3 420 pbpa R3 600 pbpa 5.26 R for a single member R for a family R for a single member R for a family

7 PLUS PLAN: FURTHER BENEFIT S EFFECTIVE FROM 1 JANUARY Wellness and preventative care (insured) benefits: Pneumococcal vaccine for beneficiaries younger than 60 years 3.11 Bankmed Stress Assessment (online stress assessment) 14.8 Pregnancy and childbirth: Additional insured pathology benefits subject to registration on the Baby and Me programme Benefits subject to registration on the Bankmed Special Care Programmes for asthma, chronic obstructive pulmonary disease, diabetes, cardiovascular disease or HIV/AIDS Benefits for beneficiaries younger than 60 years who have been diagnosed with asthma, chronic obstructive pulmonary disease, diabetes, cardiovascular disease or HIV/AIDS 100 of cost, limited to one assessment pbpa Visit to do your free online Bankmed Stress Assessment There is no limit on the number of assessments pbpa - Additional pathology at 100 of Scheme rate, subject to Baby and Me care plan /S Registration will no longer be a requirement for benefit allocation Wellness Aware Assessment renamed to Bankmed Stress Assessment Free service as of January 2016 (unlimited) Enhancement: Additional insured pathology benefits subject to registration on the Baby and Me programme PLUS PLAN: DESIGNATED SERVICE PROVIDER (DSP), PREFERRED PROVIDER AND FORMULARY S EFFECTIVE 1 JANUARY Ambulance services Preferred provider: Netcare 911 (Call ) 7.1 Hospitalisation: All Netcare, National Hospital Network (NHN), Life Hospital Network DSPs Healthcare and Mediclinic hospitals, any other independent private hospitals contracted to the Scheme, and all State facilities Preferred provider: Discovery 911 (Call ) All Netcare, National Hospital Network (NHN), Life Healthcare, Mediclinic and Clinix hospitals, any other independent private hospitals contracted to the Scheme, and all State facilities /S Discovery 911 replaces Netcare 911 Please note the inclusion of the Clinix hospital network as a DSP Disclaimer: Although every effort was made to ensure complete accuracy of this summary, errors may occur. In the event of a dispute, the registered rules will apply. 7