AXIS. CompCare Wellness Medical Scheme. Information and Benefit Guide 2018

Transcription

1 / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION / AXIS CompCare Wellness Medical Scheme Information and Benefit Guide 2018 VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd

2 AXIS CompCare Wellness Medical Scheme Information and Benefit Guide 2018

3 The AXIS option is a premium comprehensive private hospital benefit plan with post-operative rehabilitation benefits, as well as chronic and wellness benefits, for complete peace of mind. DAY-TO-DAY BENEFITS Comprehensive Wellness and Preventative Benefits Ambulance Services (Netcare911), Medical Emergencies All day-to-day PMB related benefits including Chronic Medicines Post-operative rehabilitation HOSPITAL BENEFIT Unlimited cover for in-hospital and hospital-related services ACHIEVE YOUR OPTIMAL HEALTH WITH COMPCARE WELLNESS MEDICAL SCHEME

4 IN-HOSPITAL BENEFITS Hospitalisation Members have full access to all private hospitals throughout South Africa. All hospital accounts are paid in full at a rate agreed between the Scheme and the individual hospital groups. In the case of elective admissions, authorisation must be obtained at least 48 hours before a beneficiary is admitted to a hospital or day clinic failing which a co-payment of R2 000 per admission will apply. Late authorisations will require a R1 000 co-payment. In the event of a medical emergency the scheme must be notified within one working day following the admission, failing which a copayment of R500 per admission will apply. CompCare Pre-authorisation / Co-payments are payable on specified elective procedures (excluding PMB s*) done in a hospital or a day facility and certain elective procedures are excluded. *PMB = Prescribed Minimum Benefit as defined in the Medical Schemes Act No 131 of For the co-payment schedule and list of exclusions, please refer to For the co-payment schedule, please refer to Maternity benefits Expecting mothers have access to 12 Antenatal consultations with a GP or specialist which are paid from risk (not from the Day-to-Day benefits). Confinements are subject to clinical protocols. Ultrasound pregnancy scans are limited to two 2D scans. Hospital related accounts Unless otherwise indicated in-hospital related benefits are unlimited and accounts are paid at 100% of the scheme rate. These include but are not limited to: General Practitioner visits Specialists Basic Radiology Surgical procedures Blood transfusions Auxiliary services (i.e. physiotherapy) Sports injuries While in hospital medicine is unlimited, whilst medicine prescribed on discharge (Medicines TTO) is limited to a supply of seven days. Non-PMB medicine is subject to reference pricing. Pathology (in-and-out of hospital) is limited to R PMF. Biological agents and specialised medicines are limited to R per family. A 25% co-payment is applicable. These medicines can only be obtained if pre-authorised. Surgical Prostheses (e.g. artificial joints, stents, artificial limbs) and electronic/nuclear devices (e.g. pacemaker, defibrillators, nerve stimulators and cochlear implants) are limited to an overall limit of R per family. Sub-limits per sub-category apply. Sub-limits can be viewed on the CompCare website or obtained from the CompCare Call Centre. Specialised radiology including MRI, CT scans and high resolution PET scans are limited to R PMF. Pre-authorisation is required for all MRI and CT Scans. High resolution CT Scans/PET Scans are subject to special medical motivation and also requires preauthorisation. There is no benefit for unauthorised scans, except for PMBs. No benefits are available for screening or investigative purposes. Expecting mothers are encouraged to register on the maternity programme and receive a baby bag. Please also remember to obtain pre-authorisation for the confinement. CompCare Pre-authorisation / Mental health benefits Psychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health institution. Non-Psychiatric hospital admissions are limited to R1 575 per family. Alcoholism, drug dependence and narcotism hospitalisations are only authorised in the case of PMB conditions. Pre-authorisation is required and protocols apply. Hospitalisation relating to the following conditions and procedures are covered in full for PMB conditions only: Organ and tissue transplants Renal dialysis Plasmapheresis Pre-authorisation is required and protocols apply. The following alternatives to hospitalisation are available subject to pre-authorisation and protocols and unlimited unless otherwise specified: Step-down nursing facilities, hospice and rehabilitation Terminal care (Imminent death, regardless of diagnosis) Out-of-hospital only surgical procedures in lieu of hospitalisation Oncology, including chemotherapy and radiotherapy (See limit on biological agents and specialised medicines) Wound care in lieu of hospitalisation

5 DAY-TO-DAY BENEFITS CHRONIC CONDITIONS The AXIS option provides cover for 26 chronic conditions. These include 26 conditions from the Chronic Disease List (CDL) as published in the Medical Scheme Act. For a list of chronic conditions covered in the AXIS option, please refer to Medicine benefits for CDL chronic conditions (PMBs) are unlimited with no levy or co-payment if the medicine forms part of the scheme s formulary and the price of the medicine is equal or less than the reference price for the product. Members are required to register for all CDL chronic conditions. Prior to registration on the chronic programme, only the first prescription will be paid from the acute medicine limit. Formularies and reference pricing applies. A 25% co-payment is payable for the voluntary use of non-formulary medicine. CompCare Chronic Registrations /

6 DAY-TO-DAY BENEFITS SUBJECT TO AFB All benefits are paid at 100% of the scheme rate unless otherwise specified. The Axis option covers day-to-day benefits for PMB conditions only. Post-operative rehabilitation Members have access to post-operative rehabilitation benefits for PMBs only. This benefit includes physiotherapy, occupational therapy and biokinetics and are limited to 14 days and R3 260 per beneficiary per annum. Child benefit Two visits to a General Practitioner per child younger than 6 years per annum. One additional visit at an emergency room per child younger than 6 years per annum. Limited to R1 000 per event.

7 DAY-TO-DAY BENEFITS PAID FROM RISK Emergencies Ambulance services - Emergency roadside assistance and ambulance transportation. NETCARE / In the case of non-emergency cases, authorisation must be obtained from Netcare911 at the time of transportation or within 24 hours thereof, failing which will result in a 25% co-payment. Hospital emergency room / Casualty emergency visits resulting in a hospital admission will be paid from the in-hospital benefit. Hospital emergency room / Casualty emergency visits as a result of physical injury caused by an external force will be paid in full. Child emergency benefit - members will have access to one additional visit to an emergency facility per child younger than 6 years per annum. Limited to R1 050 per event. Psychosocial counselling benefit Unlimited telephonic counselling sessions with a psychologist or social worker with the option of referral for one-on-one sessions with qualified psychologists or social workers to a maximum of 3 sessions per beneficiary per annum. Benefit relates to psychosocial counselling related to substance abuse, emotional stress, major life events e.g. birth, accidents and death, separation and loss, health care concerns, family or personal relationship issues, concerns about eldercare, childcare, parenting issues, family violence, harassment, work-related stress, balancing work and family, etc. Services provided by DSP Network of psychologists and social workers. CompCare Care Counsellors / WELLNESS AND PREVENTATIVE BENEFITS All wellness and preventative benefits are paid from risk. PREVENTATIVE BENEFITS Wellness Checks One GP wellness consultation per beneficiary per annum. Blood pressure, blood sugar, cholesterol, BMI and waist circumference one measurement per beneficiary over the age of 18 years, limited to R180 per event. Mammograms - one test per female beneficiary over the age of 35 every second year. Pap smears - one test per female over the age of 18 per annum. PSA (Prostate Specific Antigen) - one test per male beneficiary over the age of 40 per annum. Dental - one check-up per beneficiary per annum. Glaucoma test - one test per beneficiary per annum. Baby wellness visits - two visits per annum for children between 4 weeks and 18 months. Hearing and eye tests - one hearing and eye test for pre-school children aged 5 to 6 years. School Readiness Assessment (examination for admission to educational institution (only tariff codes and qualify). Career guidance (only tariff code and qualify). Vaccinations and immunisations Flu vaccinations - one dose per beneficiary per annum. HPV (cervical cancer) vaccine - one course (3 doses per registered schedule) per female beneficiary between ages 12 and 18 years. Adult pneumococcal vaccine (pneumonia) as required. Childhood pneumococcal vaccine as required. Tetanus vaccine - one injection when required. Childhood immunisations as recommended by the Department of Health up to 12 years. HEALTHY LIFESTYLE BENEFITS Fitness assessment and exercise prescription members have access to the Universal Network of biokineticists for an annual fitness assessment, exercise prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply. Fitness assessment for pregnant women members have access to one fitness assessment per pregnancy. Pre-authorisation is required and protocols apply. Nutritional assessment and healthy eating plan members have access to the Universal Network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply. Nutritional assessment for pregnant women once per pregnancy. Other preventative benefits Oral contraceptives limited to R126 per beneficiary per month. Formulary and Reference Pricing applies. Malaria Prophylaxis (prevention medicine) as required.

8 VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / This brochure is a summary of the benefits of CompCare Wellness Medical Scheme. All information relating to the 2018 CompCare Wellness Medical Scheme benefits and contributions are subject to formal approval by the Council for Medical Schemes. On joining the Scheme, all members will receive a detailed member brochure, as approved. The final registered Rules of the Scheme will apply. CompCare Wellness Medical Schemes is administered by Universal Healthcare Administrators (Pty) Ltd. COMPCARE WELLNESS MEDICAL SCHEME CONTACT US CompCare Wellness Medical Scheme Universal Place, 19 Tambach Road, Sunninghill Park, Sandton PO Box 1411, Rivonia, 2128 Tel: / Fax: correspondence@universal.co.za Web: Contact details for complaints escalated to the Council for Medical Schemes Tel: complaints@medicalschemes.com Web: GLOSSARY A Adult Dependant AFB Annual Flexi Benefit C Child Dependant CDL Chronic Disease List DSP Designated Service Provider OTC Over the Counter Medicine P Principal Member PMB Prescribed Minimum Benefits PMF Per Member Family TTO To Take Out (Medicine taken on discharge from hospital) Contributions Effective from 1 January 2018 Principal Member Adult Dependant Child Dependant Monthly R1 632 R1 632 R504 A child dependant is a dependant who is under the age of 21 years or a full time student up to the age of 27 years. An adult dependant is a dependant who is 21 years or older. These rates are only applicable to the main member and a maximum of three child dependants. / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION / INTELLIGENT / WELLNESS / INNOVATION / INTEGRITY /