Product Structure June 2010

Transcription

1 Product Structure June 2010

2 Welcome to P'La Saúde Health Plan P 'La Saúde Health Plan was established in 2006 as a medical aid scheme to provide essential affordable care to more people in Mozambique. It is a truly Mozambican registered health plan and the accumulated funds are maintained in Mozambique and reinvested here. Contributions and claims are collected and paid out from a Mozambican-based banking account in the local currency, Meticas. P'La Saúde Health Plan provides health cover for members seeking affordable cover in the private sector. P'La Saúde Health Plan is administered by Momentum Moçambique which is a subsidiary of Momentum Africa. Momentum Africa is a subsidiary of the Momentum Group with the latter being wholly owned by the FirstRand Group, a listed company on the JSE Securities Exchange with a market capitalization of over US$ 7.5 billion. FirstRand has in excess of US$ 100 billion assets under management. Momentum Africa currently administers over lives across Africa, with operations in South Africa, Lesotho, Botswana, Mauritius, Tanzania, Zambia, Kenya, Ghana, Mozambique, Swaziland, Malawi and in Namibia. You will get all the details on P'La Saúde Health Plan in this handbook which will help you to understand the different medical schemes. If you have any questions, please call

3 Why choose P'La Saúde Health Plan? You are assured of a financially sound and secure health plan The scheme, underwritten by Momentum, offers both financial stability and sustainability to ensure continued access to healthcare cover at a reasonable rate. You have access to a comprehensive and flexible product range The scheme offers members a range of benefit options with flexibility in each option to provide for you and your family s anticipated and unexpected healthcare needs. All options are rich in benefits and high in value to ensure affordability without compromising quality. Your service satisfaction is our priority At P'La Saúde we are committed to a culture of caring and strive to understand the healthcare needs of our members. We have a dedicated call centre located in Maputo, with additional service consultants looking after the well-being of our members. Product Composition Disease Management Hospital Benefits Emergency Evacuation M AJOR M EDICAL Medicine Management Health Advice Line DAY-TO-DAY Primary Care Benefits : Health Advice Line HIV/AIDS Emergency Evacuation Disclaimer To make the products and benefits easier to understand we have simplified the language and left out some of the details. The complete rules of the Scheme apply. A complete set of the rules is available in electronic format or a hard-copy at a nominal charge. 3

4 Benefit Options Corporate 4 Consultations PLATINUM OPTION 1 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT No overall annual hospital limit 16 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa

5 Consultations No overall annual hospital limit Benefits payable at 300% of agreed tariff (Mozambique Price List) PLATINUM OPTION 2 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT Emergency Evacuation to South Africa 13 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn 5

6 Benefit Options Corporate 6 Consultations PLATINUM OPTION 3 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT No overall annual hospital limit 10 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa

7 BRONZE OPTION 1 Consultations Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy Ancillary Services Hospital limit 10 visits per member per annum No Benefit 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Hospital annual limit - MT per beneficiary Benefits payable at 100% of agreed tariff (Mozambique Price List) Specialists, Doctors, etc in hospital Ward Fees (General Ward) Medicine to take home (TTO) MT per hospital episode Included in hospital limit Included in hospital limit 7 days supply Emergency Evacuation to South Africa 7

8 Benefit Options Corporate 8 Consultations BRONZE OPTION 2 Primary Care Benefit - MT per member per annum (Mozambique only) Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy Ancillary Services Hospital limit 10 visits per member per annum No Benefit 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Hospital annual limit - MT per beneficiary Benefits payable at 100% of agreed tariff (Mozambique Price List) Specialists, Doctors, etc in hospital Ward Fees (General Ward) Medicine to take home (TTO) MT per hospital episode Included in hospital limit Included in hospital limit 7 days supply Emergency Evacuation in Mozambique only

9 Benefit Exclusions Corporate The exclusions per option may differ and the list below is merely an abbreviated version of the exclusions. The rules of the Scheme will apply in all instances. Travel expenses except as provided for in terms of the benefit option chosen. Surgical appliances, except as provided by your chosen option. Reports, examinations and tests requested for emigration, immigration, visas, insurance policies, employment, admission to schools or universities, court medical reports, muscle-function tests, fitness examinations and tests, adoption of children, and for retirement due to ill-health. Operations, treatment and procedures for cosmetic reasons. Accounts for services rendered by persons not registered with a recognised professional in terms of any law. Accounts for appointments not kept by members or their dependants. Accounts in respect of: conditions for which the costs are recoverable from another party, a condition arising from willfully self-inflicted injuries, suicide or attempt to commit suicide, whether or not the person was criminally accountable, injuries arising from professional sport, power-driven vehicle sport, scuba diving, bungee or parachute jumps, appliances and medication to prevent injuries during sport and recreational activities, injuries arising from actions on account of a criminal transgression for which the member or his dependants were found guilty. Accommodation in an old-age home or institution providing general care and nursing services to persons, e.g. the infirm, aged or chronically ill patients, or similar institutions. Examinations, test and treatment of impotence and infertility or artificial insemination of a person within or outside the human body. In the case of artificial insemination, no benefit will be granted in respect of the preparatory expenses, i.e. pre-insemination expenses or insemination outside the female body. Cost in excess of the annual maximum benefits to which the member is entitled under the rules of the Scheme. Accommodation in spa s, health resorts or places of rest. The cost of holidays for recuperation purposes. 9

10 Benefit Exclusions Corporate Complications resulting from the treatment of cosmetic or unauthorised procedures. Cost arising from any person s association with the Defense Force for which he/she is covered through the Defense Force. Benefits not mentioned in this schedule or services not rendered in terms of accepted protocol or not aimed at the treatment of an actual or supposed condition or deficiency, disadvantaging or endangering essential body functions. Mammary surgery and breast reconstruction except where this is related to carcinoma, tumors and abscesses. Refractive surgery outside the benefit schedule of your chosen option. Any cost charged by a provider of service for motivations or prior motivations. Breathing exercises. Obesity and overweight. Applicators, toilet preparations, cosmetics. Hyperbaric oxygen treatment. Telephone consultations. Services rendered by social workers. Costs for services rendered outside the borders of Mozambique, unless provided for in the chosen benefit option. Elective maxilla-facial and oral surgery. Acupuncture. Biokinetics. Elective abortions (not at designated service provider (DSP)). Injuries sustained during participation in strike, during illegal picketing or riot. Organ transplants performed outside benefit schedule of chosen option. Renal dialysis performed outside benefit schedule of chosen option. Oncology and chemotherapy performed outside benefit schedule of chosen option. 10

11 Intra-ocular lens implants performed outside benefit schedule of chosen option. Breast reduction. Hospitalisation for orthodontic related surgery. Periodontal surgery. Vaccinations. 11

12 Benefit Options Small and Medium Enterprise TANZANITE OPTION Primary Care Benefit - No annual limit, co-payment required 12 General Practitioner (GP) Consultations Specialist Consultation Acute Medicine Chronic Benefit Procedures Dentistry (specialized) Optometry Physiotherapy Ancillary Services No overall annual hospital limit 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 80% cover, 20% member co-payment 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn 80% cover, 20% member co-payment Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa

13 Consultations PLATINUM OPTION 1 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT No overall annual hospital limit 14 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa 13

14 Benefit Options Small and Medium Enterprise 14 Consultations PLATINUM OPTION 2 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT No overall annual hospital limit 11 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa

15 Consultations PLATINUM OPTION 3 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT No overall annual hospital limit 8 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa 15

16 Benefit Options Small and Medium Enterprise 16 Consultations PLATINUM OPTION 4 Primary Care Benefit - MT per member per annum (Mozambique only) Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT No overall annual hospital limit 8 visits per member per annum 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation within Mozambique only

17 GOLD OPTION 1 Primary Care Benefit Medical Savings Account (MSA) - Member pre-select amount to be saved every month, ranging from MT 270 to MT Funds available in advance and any unused funds will be returned at the end of the year. Funds are used to pay for primary care needs only, as required by member. Consultations Acute Medicine Chronic Benefit Procedures Dentistry (specialized) Optometry Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) Medical Savings Account (MSA) No overall annual hospital limit Benefits payable at 300% of agreed tariff (Mozambique Price List) Emergency Evacuation to South Africa 17

18 Benefit Options Small and Medium Enterprise Consultations SILVER OPTION 3 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services MT visits per member per annum No benefit No Provided 18

19 Consultations SILVER OPTION 4 Primary Care Benefit - MT per member per annum (Mozambique only) Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy MT Ancillary Services 6 visits per member per annum No Benefit No benefit No Provided 19

20 Benefit Options Small and Medium Enterprise 20 Consultations BRONZE OPTION 1 Primary Care Benefit - MT per member per annum Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy Ancillary Services Hospital limit 8 visits per member per annum No Benefit 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Hospital annual limit - MT per beneficiary Benefits payable at 100% of agreed tariff (Mozambique Price List) Specialists, Doctors, etc in hospital Ward Fees (General Ward) Medicine to take home (TTO) MT per hospital episode Included in hospital limit Included in hospital limit 7 days supply Emergency Evacuation to South Africa

21 Consultations BRONZE OPTION 2 Primary Care Benefit - MT per member per annum (Mozambique only) Acute Medicine MT Chronic Benefit MT Procedures MT Dentistry (specialized) MT Optometry MT Physiotherapy Ancillary Services Hospital limit 8 visits per member per annum No Benefit 4x Visits to a medical practitioner 2x Ultrasound examinations 1x Full blood count, 1x Elisa test ARV Syrup for newborn Hospital annual limit - MT per beneficiary Benefits payable at 100% of agreed tariff (Mozambique Price List) Specialists, Doctors, etc in hospital Ward Fees (General Ward) Medicine to take home (TTO) MT per hospital episode Included in hospital limit Included in hospital limit 7 days supply Emergency Evacuation in Mozambique only 21

22 Benefit Exclusions Small and Medium Enterprise The exclusions per option may differ and the list below is merely an abbreviated version of the exclusions. The rules of the Scheme will apply in all instances. Travel expenses except as provided for in terms of the benefit option chosen. Surgical appliances, except as provided by your chosen option. Reports, examinations and tests requested for emigration, immigration, visas, insurance policies, employment, admission to schools or universities, court medical reports, muscle-function tests, fitness examinations and tests, adoption of children, and for retirement due to ill-health. Operations, treatment and procedures for cosmetic reasons. Accounts for services rendered by persons not registered with a recognised professional in terms of any law. Accounts for appointments not kept by members or their dependants. Accounts in respect of: conditions for which the costs are recoverable from another party, a condition arising from willfully self-inflicted injuries, suicide or attempt to commit suicide, whether or not the person was criminally accountable, injuries arising from professional sport, power-driven vehicle sport, scuba diving, bungee or parachute jumps, appliances and medication to prevent injuries during sport and recreational activities, injuries arising from actions on account of a criminal transgression for which the member or his dependants were found guilty. Accommodation in an old-age home or institution providing general care and nursing services to persons, e.g. the infirm, aged or chronically ill patients, or similar institutions. Examinations, test and treatment of impotence and infertility or artificial insemination of a person within or outside the human body. In the case of artificial insemination, no benefit will be granted in respect of the preparatory expenses, i.e. pre-insemination expenses or insemination outside the female body. Cost in excess of the annual maximum benefits to which the member is entitled under the rules of the Scheme. Accommodation in spa s, health resorts or places of rest. The cost of holidays for recuperation purposes. Complications resulting from the treatment of cosmetic or unauthorised procedures. Cost arising from any person s association with the Defense Force for which he/she is covered through the Defense Force. 22

23 Benefits not mentioned in this schedule or services not rendered in terms of accepted protocol or not aimed at the treatment of an actual or supposed condition or deficiency, disadvantaging or endangering essential body functions. Mammary surgery and breast reconstruction except where this is related to carcinoma, tumors and abscesses. Refractive surgery outside the benefit schedule of your chosen option. Any cost charged by a provider of service for motivations or prior motivations. Breathing exercises. Obesity and overweight. Applicators, toilet preparations, cosmetics. Hyperbaric oxygen treatment. Telephone consultations. Services rendered by social workers. Costs for services rendered outside the borders of Mozambique, unless provided for in the chosen benefit option. Elective maxilla-facial and oral surgery. Acupuncture. Biokinetics. Elective abortions (not at designated service provider (DSP)). Injuries sustained during participation in strike, during illegal picketing or riot. Organ transplants performed outside benefit schedule of chosen option. Renal dialysis performed outside benefit schedule of chosen option. Oncology and chemotherapy performed outside benefit schedule of chosen option. Intra-ocular lens implants performed outside benefit schedule of chosen option. Breast reduction. Hospitalisation for orthodontic related surgery. Periodontal surgery. Vaccinations. 23

24 267 Zedequias Manganhela Ave JAT 4 Building 3rd Floor Maputo Mozambique Telephone: (+258) Facsimile: (+258)