looks after you in an emergency

Transcription

1 3rd Edition Newsletter 2013 TFG Medical Aid Scheme looks after you in an emergency You have access to Discovery 911, a service that provides trained paramedics in response vehicles that will help you in a medical emergency. Call Discovery 911 in a medical emergency: When is it an emergency? It is important to know the difference between a medical emergency and general medical care as it could affect the way the Scheme pays for your claims. It also impacts on how a hospital stay is authourised, should it be required. How to identify a medical emergency The Medical Schemes Act defines an emergency as: 1. sudden and unexpected onset of a medical condition; 2. requires immediate medical or surgical treatment; and 3. if not treated immediately, will lead to death or serious impairment of a bodily function, part or organ. Your cover and what you have to do in a medical emergency TFG Medical Aid Scheme covers all life-threatening emergency medical conditions in full, because it forms part of the Prescribed Minimum Benefits. The Medical Schemes Act requires all medical schemes to cover the costs related to the diagnosis, treatment and care of: Any life-threatening emergency medical condition A defined set of 270 diagnoses 27 chronic conditions. These conditions and their treatments are known as the Prescribed Minimum Benefits. You ll find more information in your 2013 benefit brochure. You can also call us on To ensure you have full cover, contact us or get someone to contact us If you have to go to hospital in an emergency, contact us within 48 hours or get someone to contact us. We will confirm your benefits and cover for the hospital stay. If you do not let us know, it can affect your cover. Contact TFG Medical Aid Scheme within 48 hours of a medical emergency. Call: Please remember: You must always have a car sticker to confirm your identity in case of emergency. If you don t have one, you can call our service centre on to request one. 1

2 Know your benefits and make them last longer Medical bills can leave a serious dent in your pocket. The good news is that TFG Medical Aid Scheme offers tangible benefits that lower, or even eliminate, co-payments. We ve partnered with a network of healthcare professionals, and created benefit structures and payment arrangements that offer you better certainty and reduce gaps in cover. You can benefit by using healthcare professionals who we have an agreement with, because we will cover their fees for approved procedures in full. GP and specialist visits cover We will cover treatment by specialists in our network in full. If you use a specialist who we do not have an agreement with in hospital, we cover you up to 100% of the Scheme Rate. If you are treated out of hospital by a non-network specialist, we will cover you up to 80% of the Scheme Rate. You may have a co-payment if your specialist charges above these rates. We cover GPs who we have an agreement with in full, subject to your available benefit and annual limits. Non-network GP consultations performed in hospital are covered at 100% of the Scheme Rate and those performed out of hospital at 80% of the Scheme Rate. Most other healthcare providers, for example, physiotherapists, private nurses and dentists are covered up to 80% of the Scheme Rate for treatment done out of hospital and 100% of the Scheme Rate in hospital. Chronic medicine If you are registered for the Chronic Illness Benefit, you ll have full cover for approved medicine on our medicine list, or up to a set monthly amount (Chronic Drug Amount) for approved medicine not on our medicine list. If you choose to use medicine that is not on the Scheme s medicine list and get it from a pharmacy we do not have an agreement with, you will have a 40% co-payment for your prescribed medicine Note: Non-generic medicines are generally more expensive than generic alternatives. If you are experiencing copayments for using medicine that is not on this list, ask your pharmacist or prescribing doctor if there is a formulary option for your medicine that you can use to avoid this co-payment. Let MaPS help you find a healthcare professional MaPS is a website tool for finding healthcare professionals and service providers who TFG Medical Aid Scheme has an agreement with. You can access MaPS on our website at So, make sure you know your benefits and use healthcare professionals who we have an agreement with to avoid co-payments and make your benefits last longer! Avoid co-payments during hospitalisation We will cover your hospital admission from your available benefits in full and at the agreed rate. To get full hospital cover and avoid co-payments, you have to preauthorise your admission. To do this, you must call us at least 48 hours before any planned procedure or admission. In an emergency, we will cover you in full in any hospital until you have been stabilised. If you are not being treated at a hospital we have an agreement with, you may be transferred to a network provider once you are stable to ensure full cover. Some treatments you receive in hospital may need separate approval or benefit confirmation. Get full cover for your medicine Acute medicine TFG Medical Aid Scheme has a list of medicine that we cover in full. You will have a 20% co-payment if you use medicine that is not on this list, unless it has been approved by the Scheme as an exception. You can get your prescribed medicine from one of the pharmacies who we have an agreement with. If you do this, we will cover the medicine up to the Scheme Medicine Rate, which includes an agreed dispensing fee. If you use a pharmacy we do not have an agreement with, you will have a 20% co-payment. 2

3 Test your breasts it can save your life! Breast cancer is the most common cause of cancer deaths worldwide. Luckily, TFG Medical Aid Scheme will pay for your mammogram screening, which can help detect breast cancer early and save your life. Understanding what a mammogram is A mammogram is an x-ray of the breasts used to detect tumours in the breast tissue. Detecting breast cancer early means the chance of full recovery is very good. Without a mammogram, tumours can grow and spread to other parts of the body. The best time for a mammogram is one week after your menstruation when your breasts are less tender. On the day of your test, do not wear deodorant, powder or lotion under your arms or breasts. You should also try to wear a skirt or pants so you ll only need to take off your shirt for the exam. What happens if they find abnormalities in your breasts? When detected in the early stages of development, a breast tumour can be removed with minor surgery. If this isn t done, the lump can grow and spread and eventually the breast will have to be removed or you may need aggressive therapy even this is very dangerous. Remember this: Just because you don t have a family history of breast cancer or your previous mammogram result was normal, does not mean you are not at any risk. Once you reach 40, you should go for yearly mammograms. Know your health and earn Vitality points You can earn Vitality points for going for a mammogram if you are 40 years old or older. Make an appointment as soon as possible and make sure the claim is submitted so you can earn your points. For more information about preventive screening tests, visit and follow the links to Discovery Vitality. Alternatively, call TFG Medical Aid Scheme on

4 You can now earn Vitality points at the TFG Clinic TFG s on-site clinic, run by service provider Incon, is now a registered provider of the Vitality Health Check. This means you can have your tests done and earn Vitality points at the TFG clinic! What you must do to earn points Visit the TFG clinic and have the following basket of tests done to earn your points. You will earn 500 Vitality points for every test and up to points per test if your results are in a healthy range. The cost of the tests is covered by TFGMAS: Blood pressure test Blood glucose test Cholesterol test Weight assessment (body mass index) Other services available at the TFG clinic The TFG clinic gives all TFGMAS members access to certain medical services free of charge! These include: The treatment of injuries and minor illness; Family planning, cervical cancer screening, weight management, TB and STD counselling, blood pressure, cholesterol, blood sugar, PSA testing; HIV testing and counselling; and Chronic illness and disability management, for example asthma, cancer, diabetes, epilepsy, hypertension, bi-polar disorder, HIV and AIDS, and more. To book an appointment, you can call For more information on the Vitality Health Check, log in to Keep your TFGMAS contact card handy! You should have received a TFG Medical Aid Scheme contact card with your membership pack. This card has all the relevant and important numbers, addresses and website information you need to manage your membership and stay in touch with us. Information on the contact card The card has contact numbers to use: In a medical emergency; If you want to authorise your hospital admissions; To get information about the Chronic Illness Benefit, the Oncology Programme and the HIVCare Programme; To get information on where to send your claims; If you have any internet queries. You can also find the addresses of all the TFGMAS walk-in centres and the Scheme s general contact details. The card is very handy and you should keep it with you at all times. Submitting your claims You can find information on how to submit your claims to us on the contact card. You can either fax the claim to us on or send it via to claims@discovery.co.za. If you want to hand deliver the claim, you can do it at one of our walk-in centres (details also on the card). If you did not get one of these cards, you can call the Scheme on to request one. Emergency Hospital authorisations Chronic Illness Benefit Oncology Programme HIVCare Programme Discovery Mobile WAP Site Claims Fax Internet queries preauthorisations@discovery.co.za SMS Keyword to 31DIS (31347) (from a GPRS-enabled cellphone) claims@discovery.co.za

5 Helping you through the tax season Submitting your tax returns can be a daunting task. So we would like to make it easier for you to submit your returns without the associated stress. Where you can find your tax certificates Tax certificates give you the necessary information to complete your tax returns and form part of legal and legislative compliance. Tax certificates for the tax year, 1 March 2012 to 28 February 2013, have been available on from June If you have any questions, you can visit the Scheme s website or call the Discovery Health Service Centre on to request a copy of your tax certificate. Find all the information you need on TFG Medical Aid Scheme on our website New and current members can find information on TFG Medical Aid Scheme on the TFGMAS website, For example, you can get application forms to join TFG Medical Aid Scheme, add dependants or change registrations, add to or manage your benefits, as well as find forms to manage other aspects of your membership. More information at your fingertips You won t just find application forms on the website. There is also information available on the plans we offer, your benefits and cover, our wellness programme, claims and loads more. If you still can t find what you re looking for, please give us a call on All our other contact details are also available on the website. 5

6 do you have a question or concern? let us know! We at TFGMAS are committed to giving you excellent service, and we take your questions and complaints very seriously. You can contact us if you have questions about your health plan, your claims, or any other matter relating to the Scheme. How to get hold of us There are various channels you can follow, making it easier for you to get a resolution to your query. You can send your queries via to service@discovery.co.za or you can give us a call on How to escalate a query If we have to escalate your query to a particular person, we will do so. You can also find some information you might need in your Benefit Brochure or on our website at Specific contact details of the Scheme are also on the website and in your Benefit Brochure. We always welcome your feedback! Please note for vitality related articles on page 3 and 4: Vitality is not part of the Scheme. Participation or non-participation in Vitality does not impact or influence Scheme benefits. Vitality is a separate product sold and administered by Discovery Vitality (Pty) Ltd, registration number 1999/007736/07, an authorised financial services provider. 6 GM_22897DIH_13/09/2013_V6