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CompCare Wellness Medical Scheme
MUMED Information and Benefit Guide 2018
VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd
The MUMED option is a traditional option that offers above average cover, with unlimited hospital cover and day-to-day benefits consisting of flexible risk cover. Additional cover for specified services are available once the flexi risk benefit is exhausted.
CompCare Wellness Medical Scheme
MUMED Information and Benefit Guide 2018
DAY-TO-DAY BENEFITS ARE SUBJECT TO: • Annual Flexi Benefit (AFB)
BENEFITS NOT SUBJECT TO AFB • Wellness and Preventative Benefits • Ambulance Services Netcare911
HOSPITAL BENEFIT
•Unlimited cover for in-hospital and hospital-related services
ACHIEVE YOUR OPTIMAL HEALTH
WITH COMPCARE WELLNESS MEDICAL SCHEME
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 Pre-authorisation / 0860 111 090 Co-payments are payable on specified elective procedures (excluding PMBs*) done in a hospital or a day facility. *PMB = Prescribed Minimum Benefit as defined in the Medical Schemes Act No 131 of 1998. For the co-payment schedule, please refer to www.compcarewellness.co.za. Maternity benefits Expecting mothers have access to 12 Antenatal consultations with a GP or specialist which are paid from risk (not from the Day-to-Day benefits). 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 Pre-authorisation / 0860 111 090
Mental health benefits Psychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health institution. Non-Psychiatric hospital admissions are limited to R2 105 per family.
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 • Radiology • Pathology • Surgical procedures • Blood transfusions • Auxiliary services (i.e. physiotherapy) • Sports injuries Specialist accounts with the exclusion of dental accounts relating to hospital admissions are unlimited and paid at 100% of the scheme rate. Physiotherapy in hospital is limited to R6 315 per family. While in hospital medicine is unlimited, medicine prescribed on discharge (Medicine TTO) is limited to a supply of seven days. NonPMB medicine is subject to the reference pricing. Biological agents and specialised medicines are limited to R130 500 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 R38 650 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 includes MRI, CT scans and high resolution PET scans and is limited to R23 150 per family per annum. Preauthorisation 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.
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 procedures Oncology, including chemotherapy and radiotherapy (See limit on biological agents and specialised medicines) • Wound care in lieu of hospitalisation • Excimer Laser Refractive Surgery limited to the day-to-day optical limit
DAY-TO-DAY BENEFITS AFB Values for 2018
Annual Flexi Benefit (AFB) We pay your day-to-day medical expenses from the available funds in your AFB. The AFB is a risk benefit.
AFB
P
A
C
R5 658
R3 549
R1 408
PMB related benefits will be paid for from your AFB risk benefit. The AFB will be pro-rated if you join during the course of the year. Additional Cover When you run out of AFB, we will pay for specified healthcare expenses from risk. These include: • GP visits (balance of consultations only)
CHRONIC CONDITIONS The MUMED option provides cover for 36 chronic conditions. These include 26 conditions from the Chronic Disease List (CDL) as published in the Medical Scheme Act and 10 chronic conditions not listed as CDLs. For a list of chronic conditions covered in the Mumed option, please refer to www.compcarewellness.co.za. CDL and Non-CDL chronic conditions are subject to the AFB. Once the benefit is depleted, CDL medicines are unlimited. Medicine benefits for CDL chronic conditions (PMBs) are unlimited and initially paid from the member’s available AFB with no levy or copayment if the medicine forms part of the Scheme’s formulary and the Non-CDL chronic medicines are paid from the member’s available AFB. price of the medicine is equal or less than the reference price for the product. Thereafter medicines are unlimited. 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 / 0860 111 900
DAY-TO-DAY BENEFITS SUBJECT TO AFB All benefits are paid at 100% of the Scheme rate unless otherwise specified. Benefits paid from available AFB where no sub-limits are applicable
Sub-limits while AFB funds are available M: 6 visits; M+1: 8 visits: M+2: 10 visits: M+3+: 11 visits
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 which will result in a 30% co-payment. No referral required 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 A 25% co-payment is applicable to non-generic products. Reference Pricing applies to medicines where a generic product is available and might result in a co-payment
R160 per event, R560 per beneficiary per annum and R1 000 per family per annum
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 (to be recommended by a medical practitioner), chiropractors, Dieticians, homeopaths (Consultations), Naturopaths (Consultations), Speech and Occupational therapists, Chiropody/ Podiatry, Social workers, Physiotherapy and Biokineticists Mental Health- Clinical psychologists Mental Health - Psychiatry
Combined in-and-out of hospital benefit, limited to R23 150 from in-hospital benefit Subject to AFB, combined in-and-out of hospital benefit, limited to R28 940 per family
Sub-limit of R1 950 per beneficiary One test per beneficiary every second year R1 520 per beneficiary and R4 340 per family every second year R765 per beneficiary every second year, included in lenses limit R1 895 per beneficiary and R3 000 per family R1 575 per family R4 000 per family
Oxygen-home ventilation Private nursing homes Ante-natal classes Surgical and medical appliances Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators
Limited to 60 days per family 12 ante-natal classes, limited to R715 per pregnancy
DAY-TO-DAY BENEFITS PAID FROM RISK Emergencies Ambulance services- Emergency roadside assistance and ambulance transportation. NETCARE: 082 911
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.
Hospital emergency room / Casualty emergency visits not requiring admission are paid from and limited to the member’s AFB.
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.
Hospital emergency room / Casualty emergency visits resulting in a hospital admission will be paid from the in-hospital benefit.
Services provided by DSP Network of psychologists and social workers.
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 as a result of physical injury caused by an external force will be paid in full.
CompCare Care Counsellors / 0800 390 003
Child emergency benefit - If the AFB 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.
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 86211 and 86290 qualify). • Career Guidance (only tariff code 86211 and 86290 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.
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.
Contributions Effective from 1 January 2018 Monthly
COMPCARE WELLNESS MEDICAL SCHEME CONTACT US
CompCare Wellness Medical Scheme Universal Place, 19 Tambach Road, Sunninghill Park, Sandton PO Box 1411, Rivonia, 2128 Tel: 0861 222 777 / Fax: 0866 450 991 E-mail:
[email protected] Web: www.compcarewellness.co.za Contact details for complaints escalated to the Council for Medical Schemes Tel: 0861 123 267 E-mail:
[email protected] Web: www.medicalschemes.com
GLOSSARY
A – Adult Dependant AFB – Annual Flexi Benefit 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 TTO – To Take Out (Medicine taken on discharge from hospital)
Annual Benefit Amounts for 2018
Principal Member
Adult Dependant
Child Dependant
R2 772
R2 160
R780
Annual Flexi Benefit
Principal Member
Adult Dependant
Child Dependant
R5 658
R3 549
R1 408
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.
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