compcare wellness medical scheme mumed · hospital benefit •unlimited cover for in-hospital and...
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MUMEDCompCare Wellness Medical Scheme
Information and Benefit Guide 2018
CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd
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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.
MUMEDCompCare Wellness Medical Scheme
Information and Benefit Guide 2018
HOSPITAL BENEFIT•Unlimited cover for in-hospital and hospital-related services
ACHIEVE YOUR OPTIMAL HEALTHWITH COMPCARE WELLNESS MEDICAL SCHEME
DAY-TO-DAY BENEFITS ARE SUBJECT TO:• Annual Flexi Benefit (AFB)
BENEFITS NOT SUBJECT TO AFB• Wellness and Preventative Benefits• Ambulance Services Netcare911
HospitalisationMembers 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 co-payment 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.
Hospital related accountsUnless 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. Non-PMB 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. 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.
Maternity benefitsExpecting 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 benefitsPsychiatric 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.
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
IN-HOSPITAL BENEFITS
DAY-TO-DAY BENEFITS
CHRONIC CONDITIONS
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 Values for 2018
P A C
AFB 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 CoverWhen you run out of AFB, we will pay for specified healthcare expenses from risk. These include:
• GP visits (balance of consultations only)
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 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. Thereafter medicines are unlimited.
Non-CDL chronic medicines are paid from the member’s available AFB.
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
GP Consultations, procedures and materials
M: 6 visits;M+1: 8 visits:
M+2: 10 visits:M+3+: 11 visits
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 authorisedAcute 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
Over the counter medicine (OTC) and homeopathic medicineR160 per event, R560 per
beneficiary per annum and R1 000 per family per annum
Basic radiology Including black and white X-rays and ultrasound
Specialised radiology MRI, CT, High resolution CT and PET scans
Combined in-and-out of hospital benefit, limited to R23 150 from in-hospital
benefit
Pathology
Subject to AFB, combined in-and-out of hospital
benefit, limited to R28 940 per family
DentistryConservative and restorativeSpecialised 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
Sub-limit of R1 950 per beneficiary
OptometryConsultations
One test per beneficiary every second year
OptometryLenses, contact lenses and disposable lenses
R1 520 per beneficiary and R4 340 per family every
second year
OptometryFrames
R765 per beneficiary every second year, included in
lenses limit 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
R1 895 per beneficiary and R3 000 per family
Mental Health - Clinical psychologists R1 575 per familyMental Health - Psychiatry R4 000 per family
Oxygen-home ventilation
Private nursing homes Limited to 60 days per family
Ante-natal classes 12 ante-natal classes, limited to R715 per pregnancy
Surgical and medical appliancesWheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators
EmergenciesAmbulance services - Emergency roadside assistance and ambulance transportation.
NETCARE: 082 911
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 AFB.
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.
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.
Psychosocial counselling benefitUnlimited 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 / 0800 390 003
DAY-TO-DAY BENEFITS PAID FROM RISK
All wellness and preventative benefits are paid from risk.
WELLNESS AND PREVENTATIVE BENEFITS
PREVENTATIVE BENEFITS
HEALTHY LIFESTYLE BENEFITS
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.
• 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.
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).
Contributions Effective from 1 January 2018Principal Member
Adult Dependant
Child Dependant
Monthly R2 772 R2 160 R780
Annual Benefit Amounts for 2018Principal Member
Adult Dependant
Child Dependant
Annual Flexi Benefit R5 658 R3 549 R1 408
COMPCARE WELLNESS MEDICAL SCHEME
CONTACT USCompCare Wellness Medical SchemeUniversal Place, 19 Tambach Road,Sunninghill Park, SandtonPO Box 1411, Rivonia, 2128
Tel: 0861 222 777 / Fax: 0866 450 991E-mail: [email protected]: www.compcarewellness.co.za
Contact details for complaints escalated to the Council for Medical SchemesTel: 0861 123 267E-mail: [email protected]: www.medicalschemes.com
GLOSSARYA – Adult Dependant AFB – Annual Flexi Benefit C – Child Dependant CDL – Chronic Disease ListDSP – Designated Service ProviderOTC – Over the Counter MedicineP – Principal MemberPMB – Prescribed Minimum BenefitsPMF – Per Member FamilyTTO – To Take Out (Medicine taken on discharge from hospital)
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.
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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