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

Transcription

1 / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION / CompCare Wellness Medical Scheme NETWORX 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 CompCare Wellness Medical Scheme NETWORX Information and Benefit Guide 2018

3 The NETWORX option is an affordable healthcare plan with exceptional value for students and low-income employees in the corporate sector, and offers essential cover within the Universal Healthcare Provider Network. DAY-TO-DAY BENEFITS ARE SUBJECT TO: AFB: Specialist visits, basic dentistry, optometry and non-formulary prescription medication only Other day-to-day benefits e.g. GP visits, available in the Universal Provider Network BENEFITS PAID FROM RISK Wellness and Preventative benefits Chronic Medicines Ambulance Services Netcare911 HOSPITAL BENEFIT (Network of private hospitals) In-hospital and hospital related accounts subject to OAL ACHIEVE YOUR OPTIMAL HEALTH WITH COMPCARE WELLNESS MEDICAL SCHEME

4 IN-HOSPITAL BENEFITS Hospitalisation Members have full access to a Network of Private Hospitals throughout South Africa. All hospital accounts are paid in full at a rate agreed between the Scheme and the individual hospital groups. For the list of the Network of Private Hospitals please refer to In-hospital benefits are subject to an overall annual limit (OAL) of R PMF. 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 admission, failing which a copayment of R500 per admission will apply. CompCare Pre-authorisation / Specified elective procedures (excluding PMBs*) done in a hospital or a day facility are excluded on this option. For the schedule of exclusions, please refer to *PMB = Prescribed Minimum Benefit as defined in the Medical Schemes Act No 131 of Maternity 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 subject to the overall annual limit (OAL) 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, medicine prescribed on discharge (Medicines TTO) is limited to a supply of seven days and R290. Biological agents and specialised medicines are only allowed for PMBs. 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 subject to pre-authorisation.. Specialised radiology including MRI, CT scans and high resolution PET scans is limited to OAL. 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.. 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. 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 subject to OAL unless otherwise specified: Step-down nursing facilities, hospice and rehabilitation (PMB only) Terminal care (Imminent death, regardless of diagnosis) Out-of-hospital surgical procedures are only allowed in general practitioner s rooms and subject to DSP only. Procedures in specialist s rooms subject to referral by Universal Network general practitioner Oncology, including chemotherapy and radiotherapy (PMB only) Wound care in lieu of hospitalisation

5 DAY-TO-DAY BENEFITS If services are rendered by Universal Network Providers, benefits will be paid at 100% of the Scheme rate up to specified limits. Specialist visits, basic dentistry, optometry, and non-formulary prescription medication are subject to an Annual Flexi Benefit (AFB) limited to: R2 940 PB R4 380 PMF Services to be provided by healthcare providers in the approved DSP network (Universal Provider Network). CHRONIC CONDITIONS The NETWORX 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 NETWORX 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 All benefits are paid at 100% of the Scheme rate unless otherwise specified. All services must be rendered by Universal Network Providers unless otherwise specified. Benefit GP consultations, procedures and materials (In-Network) GP consultations, procedures and materials (Out-of-Network) Specialist Consultations, procedures and materials A referral from a GP is required before seeking treatment from a specialist except for services provided by an ophthalmologist, gynaecologist, oncologist or 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 Acute Medication prescribed by a specialist out-of-hospital is only covered if the member was referred by a Universal Network Care designated service provider, according to the Universal Network formulary and such medication will be available only from a Universal Network accredited pharmacy 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 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 Benefit Unlimited. Clinical motivation may be required to authorise more than 3 GP visits per beneficiary per annum 2 visits PB per annum. A 20% co-payment applies. Members are required to pay at point of service and claim back from the Scheme. Benefits per event (including medicines, pathology and radiology) and excluding facility fees are limited to R1 050 Subject to AFB. Limited to 2 visits PB and 3 visits PMF per annum for non-pmb. Two additional anti-natal visits are allowed per pregnancy. Unlimited for PMB conditions A Universal Network General Practitioner has to refer a patient. Referrals are limited to specialists located at DSP Network Hospitals only Pre-authorisation is required for each visit and any other referrals or procedures The medication will be provided as part of the acute consultation (when dispensed by a dispensing practitioner) or by an accredited designated service provider/pharmacy if prescribed by a nondispensing practitioner Benefits are unlimited, according to a fixed Universal Network medicines formulary and Universal Network protocols Out-of-network rules applies No benefit Tests are limited to the list of codes for radiology. For the schedule of radiology codes, please refer to subject to pre-authorisation and case management within a DSP Network Tests are limited to the list of codes for pathology. For the schedule of pathology codes, please refer to Subject to AFB. Limited to a Universal Network list of approved dental codes. 1 Consultation PB per year. Limited to R1 500 PB and R2 500 PMF. Subject to AFB 1 test PB per annum. Subject to AFB Limited to clear plastic single vision (limited to R820 PB) or bi-focal lenses (limited to R1 315 PB) every second year. Subject to AFB Included in lenses limit. Subject to AFB

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 seen as an out of area GP visit. 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, subject to OAL. Surgical and medical appliances Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators are paid from risk for. 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. Vaccinations and immunisations Flu vaccinations - one dose per beneficiary per annum. Other preventative benefits Oral contraceptives - limited to R126 per beneficiary per month. Formulary and Reference Pricing applies.

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 AOL Annual Overall Limit C Child Dependant CDL Chronic Disease List DSP Designated Service Provider OTC Over the Counter Medicine OAL Overall Annual Limit P Principal Member PB Per Beneficiary PMF Per Member Family PMB Prescribed Minimum Benefits TTO To Take Out (Medicine taken on discharge from hospital) Contributions Effective From 1 January 2018 Income bands Principal (R) Adult (R) Child (R) R368 R368 R R942 R894 R R990 R942 R R1 122 R1 068 R R1 194 R1 134 R R2 196 R1 974 R768 Annual Benefit Amounts For 2018 Per beneficiary Per family Annual Flexi Benefit R2 940 R4 380 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. The above 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 /