Member Training
Welcome and introduction Industry Drivers Scheme strategy Benefit Changes for 2009 Product summary Managed Care Initiatives Agenda
Industry Drivers Legislation Medical Schemes Amendment Bill National Health Amendment Bill Medicines and related substances amendment Bill
Industry Drivers cont Current Economic Environment Inflation Utilisation Technology Ageing Members Solvency Build-up Benefit increases TOTAL 11 13 % 0.5% 0.25 0.5% 3% 0 3 % 0 3% 14.75 23%
Industry Drivers cont Profile of the Scheme. Average age Membership Chronic Registration Claims History
Scheme strategy Long term growth strategy Focus on core business of providing medical-cover Conservative view for taking on risk. Align with legislation Maintain higher than legislated levels of solvency. Provide cover when needed
Benefit Changes Benefit limits increased by approximately 10% Optical (PPN) benefit cycle - 2 years on all traditional options All Dental benefits covered at 75% TT Maternity Program - except Network Option 12 Antenatal Consultations 2 Scans Vitamins
Benefit Changes for the Incentive Comprehensive Benefit limits have been increased by approximately 10% The threshold levels have been increased by 10% Claims accrue to threshold at 90% of TT Above threshold benefits will be covered at 90% of TT Non-PMB chronic medication = 75% TT A 75% benefit for all Dentistry A R1000 co-payment on out of hospital MRI and CT scans Maternity Program
Contribution Increases 2009 Topmed 100% 15.8% Topmed 80% 15.8% Limited 100% 15.8% Incentive Savings 16.8% Incentive Comprehensive 17.5% Topmed Network 16.8% Topmed Hospital 16.8% Average contribution increase 16.7%
BENEFIT CATOGORY 2009 Benefits TOPMED 100% TOPMED 80% HOSPITAL BENEFIT Unlimited / Any Provider 100% AT (ER 24) Unlimited / Any Provider 100% AT (ER 24) MAJOR MEDICAL Post Operative Hip- & Knee replacement, Post Crime Trauma Stroke Heart Attack Post Operative Hip- & Knee replacement, Post Crime Trauma Stroke Heart Attack CHRONIC M R46 000 M+ R92 000 PMB s DAY TO DAY BENEFITS Generous benefits MRI/CT 100% TT M R14 000 80% M+ R28 200 80% PMB s Generous benefits MRI/CT 80% TT DENTISTRY DENIS - 75% TT DENIS 75% TT
BENEFIT CATOGORY HOSPITAL BENEFIT MAJOR MEDICAL CHRONIC DAY TO DAY BENEFITS DENTISTRY 2009 Benefits LIMITED 100% Overall Annual Limit Any Provider 100% AT M R231 000 M+ R 460 000 (ER24) Post Operative Hip- & Knee replacement, Post Crime Trauma Stroke Heart Attack M R3450 M+ R6850 + PMB s Limited day to day Benefits 100% TT MRI/CT R1000 Co-pmt DENIS 75% TT INCENTIVE COMPREHENSIVE Unlimited Any Provider 100% AT (ER24) Post Operative Hip- & Knee replacement, Post Crime Trauma Stroke Heart Attack 75% benefit for non PMB s M R 7050 M+ R14150 +PMB s Savings 15% - 100% cost (90% of TT accrue to Threshold) ATB 90% TT MRI/CT R1000 Co-pmt DENIS - 75% TT
BENEFIT CATOGORY 2009 Benefits INCENTIVE SAVINGS NETWORK OPTION HOSPITAL PLAN HOSPITAL BENEFIT Unlimited / Any Provider 100% AT (ER24) Unlimited / Any Provider 100% AT (ER24) Unlimited / Any Provider 100% / 150% AT (ER24) MAJOR MEDICAL Post Operative Hip- & Knee replacement, Post Crime Trauma Stroke Heart Attack n/a Post Operative Hip- & Knee replacement trauma only Post Crime Trauma Stroke Heart Attack CHRONIC PMB s Formulary / DSP PMB s Formulary / DSP PMB s Formulary / DSP DAY TO DAY BENEFITS Savings 15% 100% cost MRI/CT R1000 Co pmt Prime Cure provider Out of network R 650 (80%) Specialist R1 650 DENTISTRY DENIS 75% TT Basic Dentistry PRIME CURE No day to day benefits MRI/CT R1000 Co-pmt No Benefit
Rates per option Hospital Plan Network Option Incentive Savings Incentive Comp. Principle R709 R701 R1050 R1722 Adult Dependant R492 R523 R644 R1242 Child Dependant R266 R292 R294 R485 Limited 100 100% Option 80% Options Principle R1612 R3837 R2472 Adult Dependant R1228 R3611 R2046 Child Dependant R474 R1070 R652
Extended Major Medical Extended rehabilitation benefits, funded from Risk Post Hip Replacement: (Hospital plan trauma events only) - Physiotherapy x 8 sessions within 3 Months Post Knee Replacement: Physiotherapy (Hospital Plan trauma events only) - Physiotherapy x 8 sessions within 3 Months Post Crime Trauma: 12 x combined consultation for - 6 Months to a Psychologist, Psychiatrist or Social Worker * Benefits not available on Topmed Network
Extended Major Medical Cont Heart Attack: Cardiac Rehabilitation Programme - Case Management Stroke: Physiotherapy, Occupational Therapy & Speech Therapy Case Management Authorise all benefits through Topmed Pre-authorisation centre * Benefits not available on Topmed Network
Managed Care Initiatives Chronic Medication Maternity Program Oncology HIV Denis Extended Major Medical PPN Pre-Authorisation
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