UNISAVE Information and Benefit Guide CompCare Wellness Medical Scheme

Transcription

1 / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION / CompCare Wellness Medical Scheme UNISAVE 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 The UNISAVE option offers comprehensive unlimited hospital cover. A flexible savings account allows a member to pay for day-to-day healthcare requirements at the member s own discretion. UNISAVE CompCare Wellness Medical Scheme Information and Benefit Guide 2018

3 DAY-TO-DAY BENEFITS ARE SUBJECT TO: Personal Medical Savings Account (PMSA) BENEFITS PAID FROM RISK All PMBs Chronic Medicines Ambulance Services, Netcare911 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 Chronic Registrations / 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 Maternity benefits Expecting mothers have access to 12 Antenatal consultations with a GP or specialist which are paid from risk (not the PMSA). Confinements are subject to clinical protocols. Ultrasound pregnancy scans are limited to two 2D scans. 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 Chronic Registrations / Mental health benefits Psychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health institution. 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 Radiology Pathology 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 the reference pricing. Pathology (in and out of hospital) is limited to R PMF Physiotherapy in hospital is limited to R6 840 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 is limited to R PMF. The first R1 000 of the specialised radiology account will be paid from the member s Personal Medical Savings Account. 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 pre-authorisation. There is no benefit for unauthorised scans, except for PMBs. No benefits are available for screening or investigative purposes. 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 surgical prosthesis Oncology, including chemotherapy and radiotherapy (See limit on biological agents and specialised medicines)

5 DAY-TO-DAY BENEFITS Personal Medical Savings Account (PMSA) We pay your day-to-day medical expenses from the available funds in your PMSA. Any unused funds will be carried over to the next year. PMSA values for 2018 P A C Monthly Savings R539 R462 R162 Annual Savings R6 468 R5 544 R1 944 The PMSA will be pro-rated if you join during the course of the year. CHRONIC CONDITIONS The UNISAVE 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 UniSave 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. Non-CDL chronic medicines are paid from the member s available PMSA for registered conditions. Members are required to register for all CDL and non-cdl applicable covered 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 PMSA All benefits are paid at 100% of the scheme rate unless otherwise specified. Benefits paid from available funds in PMSA where no sublimits are applicable Sub-limits whilst PMSA funds are available GP consultations, procedures and materials Specialist consultations, procedures and materials Paid at 100% of the scheme rate A referral from a GP is required before seeking treatment from a specialist, failure of which will result in a 30% co-payment. No referral required for services provided by an ophthalmologist, gynaecologist, oncologists or a urologist (for beneficiaries over the age of 40) and a paediatrician in respect of children under the age of 2 years or where multiple visits to a specialist are authorised Acute medicines Prescription medicines - Schedule 3 and higher A 25% co-payment is applicable on non-generic products. MMAP (Maximum Medical Aid Price) applies to medicines where a generic product is available and might result in a co-payment Over the counter medicine (OTC) and homeopathic medicine Basic radiology Including black and white X-rays and ultrasound Specialised radiology MRI, CT, High resolution CT and PET scans Pathology Dentistry Conservative and restorative The first R1 000 is payable from PMSA, except for PMBs, thereafter limited to a combined in-and-out of hospital limit of R R150 per event, R525 per beneficiary per annum and R950 per family per annum Specialised dentistry Dentures, crowns, bridgework, metal fillings and inlays, orthodontics, prosthodontics, periodontics, Osseo integrated implants including the cost of the appliances and prosthesis, maxillofacial and oral surgery Optometry Consultations Optometry Lenses, contact lenses and disposable lenses Optometry Frames Auxiliary services Including audiologist, chiropractors, dieticians, homeopaths (consultations), naturopaths (consultations), speech and occupational therapists, chiropody/ podiatry, social workers, physiotherapy and biokineticists Mental Health - Clinical psychologists Mental Health - Psychiatry Oxygen home ventilation Private nursing homes Ante-natal classes Surgical and medical appliances Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators Benefit every second year Benefit every second year Benefit every second year 12 Ante-natal classes up to a maximum of R715 per pregnancy

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 not requiring admission are paid from and limited to the member s PMSA. 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. 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 / Child emergency benefit - if the PMSA is depleted 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. WELLNESS AND PREVENTATIVE BENEFITS All wellness and preventative benefits are paid from Risk and will not impact your savings account (PMSA) unless otherwise specified. 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 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 PMSA Personal Medical Savings Account TTO To Take Out (Medicine taken on discharge from hospital) Contributions Effective from 1 January 2018 Monthly Principal Member Adult Dependant Child Dependant Risk R1 621 R1 380 R486 Savings R539 R462 R162 Total R2 160 R1 842 R648 Annual Benefit Amounts for 2018 Principal Member Adult Dependant Child Dependant Annual Savings R6 468 R5 544 R1 944 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 /