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Netcare You’re in safe hands Dis-chem Pharmacists who care
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nThe Mumed Efficiency Discounted option 2015You can look forward to exceptional value and benefits for 2015.
Day-to-day benefits
The Mumed Efficiency
Discounted(ED) option
The Mumed ED option is an affordable plan with
traditional benefits for young members who are prepared
to go to a DSP Hospital and Pharmacy.
Understanding your day-to-day benefits in 2 easy steps
Additional BenefitsOnce the AFB has been depleted, you have unlimited
benefits for basic dentistry and the balance of the allocated GP visits for the remainder of the year
Annual Flexi Benefit (AFB)Claims are paid from the Annual Flexi Benefit (AFB)
1
Step 1Day-to-day healthcare claims are paid from the AFB. The AFB is a risk benefit, meaning that the “Scheme” pays for it.
Step 2When the AFB is depleted, you will qualify for unlimited basic dentistry benefits and the balance of the allocated GP visits until the end of the year.
Mumed Principal Adult Child
Annual Flexi Benefit (AFB)
4 944 3 096 1 236
This is how you can earn 20% towards your day-to-day benefits:
1. Make use of a Universal Network Provider for GP, Dental or Optometry benefit
2. Use a Universal Network Provider to refer you to a specialist
3. Earn money through certain wellness activities
NEW!
2Day-to-day benefits
Your day-to-day benefits and limits
BenefitClaims initially paid
from AFB
Additional benefits payable once the AFB
is depleted
Claims paid from Risk (not subject to the AFB)
Limits
General Practitioners
Paid at 100% of AT, limited to:M: 6 visitsM+1: 8 visitsM+2: 10 visitsM+3+: 11 visitsUtilisation of a GP in the Universal Network, will earn you 10% of the payment amount into your Additional AFB++ account
Specialist consultationsPaid at 100% of AT. Utilisation of a Universal Network GP for a referral to a specialist will earn you 10% of the payment amount into your AFB++ account
Acute medication Subject to formulary and RP
Over-the-counter medication (OTC)Limited to one script per day and a maximum of R145 per eventAnnual limit R490 p/b and R865 p/f
Chronic medication 26 CDL’s and 1 non-PMBMedicines must be obtained from a Dischem non use of a DSP will attract a 25% co-payment
UnlimitedReference pricing applies
Basic radiology including black and white X-rays and ultrasound100% ATLimited to R25 840 – combined in-and-out-of-hospital benefit
Specialised radiology including MRI/CT and PET scanPaid at 100% ATLimited to R13 100 p/f – combined in-and-out-of-hospital benefitPre-authorisation required
Basic pathology100% ATLimited to R19 550
Basic dentistryPaid at 100% AT. Unlimited once the AFB is depleted. Utilisation of a provider in the Universal Network will earn you 10% of the payment amount into your AFB++ account
Specialised dentistryPaid at 100% ATLimited to R1 700 p/b
Optical including: optical consultation contact lenses, framePaid at 100% AT, 1 optical consultation per annum. Lenses and frames limited to R1 315 p/b and R3 795 p/f, frame sub-limit of R660 p/b. Utilisation of a provider in the Universal Network will earn you 10% of the payment amount into your AFB++ account
Auxiliary services including:Audiologists, chiropractors, dieticians, homeopathic consultations, naturopathic consultations, speech and occupational therapists, chiropody/podiatry, social workers, physiotherapy and biokinetics
Paid at 100% ATLimited to R1 645 p/b and R2 615 p/f
Clinical psychologistsPaid at 100% AT Limited to R1 375 p/b and R3 455 p/f
Day-to-day benefits3Your day-to-day benefits and limits
BenefitClaims initially paid
from AFB
Additional benefits payable once the AFB
is depleted
Claims paid from Risk (not subject to the AFB)
Limits
Psychiatry Paid at 100% AT, Limited to R3 455 p/f
Surgical and medical appliances including:Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators
100% of costLimited to R6 850 p/f, sub-limits apply
Oxygen home ventilation Subject to pre-authorisation, PMB’s and protocols
Private nursing at homeSubject to pre-authorisation and protocolsIn lieu of hospitalisation (excludes post partum cases)
Ante-natal classes100% ATLimited to R615
Ambulance services100% of cost, unlimitedPreferred provider
Hospital emergency not requiring admissionSubject to PMB’sExcludes facility fees
Hospital emergency as a result of a physical injury caused by an external force100% ATSubject to PMB’s and protocols
4Wellness benefits
BenefitClaims paid from Risk
(not subject to the AFB)Limits
Universal 360° check including:Blood pressure, cholesterol, glucose, BMI, waist circumference, exercise plan, meal plan
Limited to R155 p/b1 per year p/b over the age of 18 years at DSP
Flu vaccinations Limited to R80 p/b
HPV (Cervical Cancer) One course (3 doses per registered schedule) per female beneficiaries between the ages of 12 and 18
Adult Pneumococcal Vaccine Subject to pre-authorisation, for beneficiaries over the age of 60
Tetanus vaccine One injection when required
Malaria prophylaxis As required
Mammogram One test per female beneficiary over the age of 35, every 24 months
Pap smear One test per female beneficiary over the age of 18 per annum
Prostate Specific Antigen (PSA) One test per male beneficiary over the age of 40 per annum
Quit smoking programmeLimited to R2 810, once in a lifetime.Cost of programme will be refunded after cotinine test proofs non-smoking
Glaucoma Screen Test One per beneficiary per year
Fitness Assessment and exercise prescription:
Access to Universal Network Biokineticists for:Annual fitness assessment
Exercise prescription Regular monitoring
Nutritional assessment and healthy eating plan:
Access to the Universal Network of dieticians for: Annual assessment
Healthy eating plan prescription Regular monitoring
Strict Protocols apply Strict Protocols apply
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Oral contraceptives Limited to R110 p/b per month
Emo
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Unlimited telephone counseling with referral for
one-on-one counseling to a maximum of
3 sessions per annum
Baby wellness visitTwo visits per annum for children between 4 weeks and
18 months at a DSP
Baby bag or voucher Value of R1 000
Childhood immunisationsApplicable to children up to the age of 12 years, as per
recommendation of the Department of Health
School readiness 5 - 7 years old
Psychometric testing 14 - 18 years
NEW!
Hospital benefits5The Mumed ED option offers comprehensive in-hospital benefits. As a member of the Mumed ED option you are covered at 100% of the AT whilst in hospital. You must go to a Netcare hospital and all services in hospital have to be pre-authorised.
Alternatives to hospitalisation are also covered on the Mumed ED option. Benefits are available for step-down nursing facilities, Hospice and rehabilitation, subject to pre-authorisation, protocols and case management.
Co-payments are payable on specified elective procedures (excluding PMBs) done in a hospital or a day facility. The following treatment requires a R1 000 co-payment: Excision lesion (benign & malignant)
The following treatments require a R1 500 co-payment: Gastroscopy, colonoscopy, cystoscopy, nasal/sinus endoscopy, functional nasal surgery (septoplasty), hysteroscopy, flexible sigmoidoscopy, arthroscopy, diagnostic laparoscopy, dental, conservative back and neck treatment (spinal cord injections)
The following treatments require a R2 000 co-payment: Laparoscopic Hemi-colectomy, Laparoscopic Inguinal hernia repair and Laparoscopic Appendicectomy.
The following treatment requires a R3 000 co-payment: Hysterectomy (except for cancer)
The following treatments require a R8 000 co-payment: Joint replacements (arthroplasty), laminectomy and spinal fusion and Nissen fundoplication (reflux surgery)
In-hospital benefitsBenefit Unlimited Limited Description
Overall annual limit100% ATR1.5 million p/f. Limit for non-PMB events
Netcare hospitals. Nursing homesSubject to pre-authorisation. Co-payment for non-authorisation and voluntary non use of Netcare
Ward fees: General, High care, Intensive care
100% ATSubject to pre-authorisation
Theatre fees100% ATSubject to pre-authorisation
Medication whilst in hospital 100% AT
Take-out medication Subject to MRP and formulary, limited to 7 (seven) days
GP costs whilst in hospital 100% AT
Specialist costs whilst in hospital 100% AT
Surgical prostheses and electronic nuclear devices
100% ATSub-limits apply, Refer to details on next page
Basic radiology 100% ATLimited to R25 840 p/f
Basic pathology100% ATLimited to R19 550 p/f
Specialised radiology including MRI/CT and PET scans
100% AT, combined in and out of hospital benefit limited to R13 100 p/f, pre-authorisation required
Confinements
100% AT, Pre-authorisation required, Normal birth limited to 3 days and caesarean section limited to4 days in-hospital, 12 ante-natal visits and 2x 2D scans. Payable at 100% of AT
Physiotherapy100% ATLimited to R5 225 p/f, subject to protocols
Mental health: psychiatric hospitalisation
Limited to 21 days p/fSubject to protocols and PMB’s, DSP only
Alcoholism, drug dependence and narcotism
PMB’s only
Organ transplants, plasmapheresis, renal dialysis
PMB’s only, subject to pre-authorisation and protocols, DSP only, Includes the transportation of the organ, surgically related procedures, professional fees and immunosuppressant drugs
Biological agentsLimited to R112 360, 25% co-payment, subject to pre-authorisation, protocols apply
Professional Sports injuries Subject to pre-authorisation, protocols apply
Oncology Subject to pre-authorisation and protocols apply
Alternatives to hospitalisationBenefit Unlimited Limited Description
Step-down nursing facilities, hospice and rehabilitation
100% AT, subject to pre-authorisation and protocols
Surgical procedures out-of-hospital
100% AT, subject to pre-authorisation and protocols
Radial Keratotomy /Eximer Laser
Limited to optical benefitSubject to pre-authorisation, protocols and qualifying criteria, limit includes all related services and hospitalisation
6Hospital benefits
Surgical prostheses limits
Prescribed minimum benefits (PMBs)
Procedure (Non-PMB) MumedOverall Annual Limit for internal prosthesis (OAL) 35 000 Coronary Artery stents (subject to OAL)Plain (max of 3) 11 000 Medicated (max of 3) 17 000 Other Stents (subject to OAL)Aortic aneurysm stents Subject to AHL Carotid stents 15 000 Renal stents 5 000 Aneurysm coils 35 000 Heart valves (subject to OAL) 22 000
Orthopaedic Prostheses (subject to OAL) 2 Per family per
yearHip prosthesis 37 500Knee prosthesis 37 500Shoulder prosthesis 37 500Elbow prosthesis 37 500Ankle prosthesis 25 000 Wrist prosthesis 25 000 Finger prosthesis 20 000 Spinal instrumentation - per level limited to 2 levels and one procedure per beneficiary per year
22 000
Spinal cages 11 000 Spinal implantable devices e.g balloons, cement used in kyphoplasty 25 000 Internal Fixators for fractures - pins, wires, intermedullary screws etc 25 000 Artificial limbs (subject to OAL)Through knee 50 000Below knee 38 000Above knee 44 000Partial foot 19 000 Partial hand 12 000 Below elbow 35 000Above elbow 40 000Other prostheses (subject to OAL)Intra occular lenses 4 000 Bladder sling 6 000 Hernia Mesh 8 000 Vascular grafts 24 500 Electronic and Nuclear devices (subject to PMBs)Internal Cardiac defibrillator Subject to OAL Single chamber pacemaker Subject to OAL Dual chamber pacemaker Subject to OAL Internal nerve stimulators EXCLUDED Cochlear implants EXCLUDED Insulin pumps EXCLUDED
Prescribed minimum benefits relating to hospitalisation, chronic conditions including HIV are covered at 100% of cost, subject to treatments protocols formularies and DSP’s.
Cover for chronic conditionsThe Mumed option covers 27 chronic conditions. The list of 27 chronic conditions are made up of 26 PMB CDL conditions and 1 additional non-PMB conditions. If you are diagnosed with one of the condition on the list, you need to register with Universal 086 011 1900 in order to qualify for the chronic benefit. The 27 conditions are payable from a risk benefit, and does not impact on your day-to-day benefits.
Chronic medication is subject to a formulary (list of medication) and the Reference Pricing (RP).
The conditions covered on the Mumed option are:Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Arrhythmias, Cardiomyopathy, Chronic Renal Failure, Congestive Cardiac Failure, Chronic Obstructive, Pulmonary Disease, Coronary, Artery Disease, Crohn’s Disease, Diabetes Insipidus, Diabetes Mellitus type 1 and 2, Epilepsy, Glaucoma, Haemophillia, Hiv/Aids, Menopause/Hormone Replacement Therapy, Hypercholesterolaemia/Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis
Contributions the Mumed Efficiency Discounted option
Mumed Principal Adult Child
R0 – 6 000 1 296 1 000 366
R6 001 – 7 900 1 426 1 105 408
R7 901 – 15 000 1 548 1 211 436
R15 001+ 1 717 1 337 479
A child dependant is a dependant who is under the age of 21 years. An adult dependant is a dependant who is 21 years or older. The above rates are only applicable to the member and a maximum of three of his/her child dependants.
GlossaryCompCare Medical Scheme
PMB Prescribed Minimum BenefitCDL Chronic Disease ListP/F Per familyP/B Per beneficiaryRP Reference PricingTTO To Take Out i.e. medicines taken out of hospital when dischargedAFB Annual Flexi BenefitAT Agreed TariffDSP Designated Service ProviderOTC Over The Counter Medicine
This brochure is a summary of the benefits of CompCare Wellness Medical Scheme. All information relating to the 2015 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.
Administered by Universal Healthcare Administrators (Pty) Ltd
Contact detailsContact details for complaints
escalated to the Council forMedical Schemes:
Tel: 086 112 3267E-mail: [email protected]
Web: www.medicalschemes.com
Universal Place, 19 Tambach Road Sunninghill Park, Sandton | PO Box
1411, Rivonia, 2128
Tel: 086 122 2777 | Fax: 011 208 1028E-mail: [email protected]
Website: www.compcarewellness.co.za