How the scheme works ultimax ultima 200 R

Transcription

How the scheme works ultimax ultima 200 R
S
S
BENEFIT
K
RIS
- DAY B
Chronic
Disease
Benefit
ultima 200
IT
Savings
Savings
ENE
F
Chronic
Disease
Benefit
ultimax
Major
Medical
Benefit
- TO
OHEB
ITS
Major
Medical
Benefit
O - D AY B E N E F
Threshold
Benefit
AY
BE
D
Y-T
RISK
ITS
DA
F
NE
How the scheme works
Major Medical Benefit
All costs for hospitalisation are covered from this benefit and must be pre-authorised.
Chronic Disease Benefit
Medication for approved chronic diseases is covered from this benefit.
Threshold Benefit
The Threshold Benefit pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have been accumulated to the required level.
There is no Threshold Benefit on Ultima 200.
Day-to-Day Benefit
Ultima Range
Ultimax and Ultima 200
Day-to-day expenses are covered from the Savings and Out-of-Hospital Benefit (OHEB) on Ultimax and from Savings only on Ultima 200.
ultimax
From
Hospitalisation
Major
Medical
Benefit
R7 455pm
No overall annual limit
ultima 200
From
R2 393pm
No overall annual limit
Network GPs and Specialists
Unlimited cover at cost with Fedhealth Network GPs and Specialists
Non-network GPs
Up to 100% of Fedhealth Rate
Non-network Specialists
Up to 300% of Fedhealth Rate
Up to 100% of Fedhealth Rate
Other healthcare professionals
Up to 300% of Fedhealth Rate
Up to 200% of Fedhealth Rate
Chronic Disease Benefit
65 Conditions
R24 100 per beneficiary
R40 100 per beneficiary
65 Conditions
R4 020 per beneficiary
R7 230 per beneficiary
R11 900 Threshold Level
Self-Payment Gap
R4 802
R324 per member p.a.
Day-to-Day Benefit
R7 098 per member p.a.
Unlimited GP visits at Fedhealth
Network GPs
Adult = R276
Child = R84
ultima options Ultimax and Ultima 200
[ 1
major medical benefit
All costs for hospitalisation are covered from this benefit and must be pre-authorised
ultimax
BENEFIT
ultima 200
ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED
Overall annual limit (OAL)
Unlimited
Healthcare Professional Tariff (HPT)
- Fedhealth Network GPs and Specialists
Covered at cost
Covered at cost
- Non-Fedhealth Network GPs
Covered at 100% of FR
Covered at 100% of FR
- Non-Fedhealth Network Specialists
Covered at 300% of FR
Covered at 100% of FR
- Other Healthcare Professionals
Covered at 300% of FR
Covered at 200% of FR
Prescribed Minimum Benefits (PMBs)
Unlimited in state hospitals
Hospitalisation costs
Unlimited at negotiated tariff
Co-payments
See co-payment table on page 4
Alternatives to hospitalisation
Sub-acute facilities, physical rehabilitation facilities, nursing services, private nurse practitioners & nursing agencies
Unlimited at negotiated tariff
Ambulance services
Unlimited with Europ Assistance
Appliances, external accessories, orthotics, blood, blood equivalents and blood products
Unlimited at cost
Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics)
Unlimited (See HPT above)
Maxillo-facial surgery
Including surgical extraction of impacted wisdom teeth
Unlimited, subject to approval (See HPT above)
Co-payment applies to surgical extraction of impacted wisdom teeth
Emergency treatment in a casualty ward
Unlimited at FR
Female health benefit: contraceptives
Unlimited at MPL
Immune deficiency related to HIV infection
Oncology
- Specialised medication (also see page 4)
Organ transplant including immunosuppression medication
- Corneal graft
Unlimited (See HPT above)
Unlimited. Subject to
Enhanced Protocols (See HPT above)
R373 000. Subject to Enhanced Protocols. DSP-ICON above limit
(See HPT above)
R297 000
R148 000
Unlimited (See HPT above)
R373 000 (See HPT above)
R17 800 per beneficiary
R17 800 per beneficiary
ultima options Ultimax and Ultima 200
[ 2
major medical benefit
(continued)
ultimax
BENEFIT
ultima 200
ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED
Pathology, radiology (general)
Unlimited at FR
Post-hospitalisation benefit
Up to 30 days after discharge at FR
Post-natal midwifery benefit
4 consultations per pregnancy at FR
Prostheses
- Internal
- External
Psychiatric services
Renal Dialysis (chronic)
- Haemodialysis and peritoneal dialysis
Specialised medication benefit (eg. biologicals) - oncology & non-oncology
Various sub-limits apply
(See page 5)
R18 600
Various sub-limits apply
(See page 5)
R14 800
R36 400 (See HPT above)
R25 100 (see HPT above)
Unlimited at FR
R373 000 at FR
R297 000
R148 000
Specialised radiology
Unlimited at FR
Take-out medicines
7 days medication per hospital event at MPL
Terminal care benefit
HPT - Healthcare Professional Tariff
R26 500 at FR
DSP - Designated Service Provider
MPL - Medicine Price List
ICON - Independent Clinical Oncology Network
FR - Fedhealth Rate
co-payments
ultimax
PROCEDURE
ultima 200
CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL / FACILITY BILL ONLY
Surgical extraction of impacted wisdom teeth
R3 360
Rhizotomies and facet pain block
(limited to 1 of either procedures per beneficiary per year)
R3 600
Balloon Sinuplasty
R5 930
Arthroscopic procedures
Ankle, Hip, Knee, Shoulder, Wrist
R2 010
Laparoscopic procedures
Appendectomy, Diagnostic, Hernia repairs (other than inguinal hernia repair), Nissen/ Toupey
All arthroscopic and laparoscopic procedures not listed above
R2 010
Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered
ultima options Ultimax and Ultima 200
[ 3
internal prosthesis benefit table
This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prosthess paid at cost subject to limits
ultimax
BENEFIT
ultima 200
ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED
Detachable platinum coils
R45 308
Cardiac stents
R42 728
Cardiac valves
R38 018
Cardiac pacemakers
R50 354
Carotid stents
R18 280
Aorta stent grafts
R50 354
Peripheral arterial stent grafts
R34 205
Embolic protection devices
R45 308
Shoulder replacement
R40 373
Elbow replacement
R40 373
Hip replacement
R40 373
Knee replacement
R40 373
Bone lengthening devices
R40 373
Spinal plates and screws
R40 373
Other approved spinal implantable devices
R40 373
Intraocular lenses (per lens)
R2 804
Combined benefit limit for all unlisted internal prosthesis
R31 289
screening benefit
This benefit provides access to a number of screening and preventative programmes aimed at improving members’ health
ultimax
BENEFIT
Women’s Health
Breast cancer screening with mammography
Cervical cancer screening (PAP smear - test only)
Liquid based Cytology will be reimbursed up to the rate for a standard PAP smear
Children’s Health
Immunisation Programme
ultima 200
CRITERIA
ALL LIMITS ARE PER BENEFICIARY
Women; ages 50 to 74
Women; ages 21 to 65
1 every 3 years
1 every 3 years
As per State EPI
As per State EPI
ultima options Ultimax and Ultima 200
[ 4
screening benefit
(continued)
ultimax
BENEFIT
Cardiac Health
Cholesterol screening (full lipogram)
Geriatric Health
Pneumococcal vaccination
Bone densitometry
Colorectal cancer screening (faecal occult blood test)
General
Flu vaccination
ultima 200
CRITERIA
ALL LIMITS ARE PER BENEFICIARY
All lives; aged 20 years and older
1 every 5 years
All lives; older than 65
Women; older than 65
All lives; ages 50 to 75
1 per lifetime
1 per lifetime
1 every 2 years
All lives
1 every year
EPI - Expanded Programme on Immunisation
chronic disease benefit
Medication for approved chronic diseases is covered from this benefit
ultimax
COVER
Limit
R24 100 per beneficiary, subject to an overall limit of R40 100 per family per year
IN-BENEFIT (Lists 1 and 2 below)
Conditions covered
65 conditions
See lists 1 & 2 below
Formulary
No formulary restrictions
Designated Service Provider (DSP)
Service provider of choice
OUT-OF-BENEFIT (List 1 below only)
Formulary
Comprehensive formulary
Designated Service Provider (DSP)
Service provider of choice
HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS
Limit
In-benefit means that you have not exhausted your Chronic Disease Benefit.
Out-of-benefit means that you have exhausted your Chronic Disease Benefit limit.
Non-compliance with DSP and/ or formulary requirements, as per the specific option will attract a co-payment of 40%.
If this is in respect of a PMB condition, then the co-payment is not refundable from Savings.
All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee.
Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply.
Unlimited
ultima options Ultimax and Ultima 200
[ 5
chronic disease benefit
(continued)
CHRONIC CONDITIONS LISTS
LIST 1. PMB Conditions (both options): Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, COPD/Emphysema/Chronic Bronchitis, Chronic Renal Disease, Coronary Artery Disease, Crohn’s Disease, Diabetes Insipidus,
Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism,
Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis
LIST 2. (Ultimax and Ultima 200): Alzheimer’s Disease, Angina, Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Barrett’s Oesophagus, Benign Prostatic Hyperplasia, Bulimia Nervosa, Conn’s Syndrome, Cushing’s Syndrome, Cystic Fibrosis,
Deep Vein Thrombosis, Depression, Dermatomyositis, Gastro-Oesophageal Reflux Disease, Generalised Anxiety Disorder, Gout, Hypoparathyroidism, Menopause, Motor Neuron Disease, Muscular Dystrophy, Myaesthenia Gravis, Narcolepsy, Obsessive Compulsive Disorder, Osteoporosis, Paget’s Disease, Pancreatic Disease, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Pemphigus, Polyarteritis Nodosa,
Post-Traumatic Stress Syndrome, Pulmonary Interstitial Fibrosis, Scleroderma, Stroke, Thromboangitis Obliterans, Thrombocytopaenic
Purpura, Tourette’s Syndrome, Valvular Heart Disease, Zollinger Ellison Syndrome
day-to-day benefit
Day-to-Day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses Benefit (OHEB) and carry over Savings on Ultimax and from Savings only on Ultima 200. On Ultimax, limits may apply when calculating certain claims for accumulation
to Threshold as well as for refunds from OHEB and Threshold. Ultima 200 does not have an Out-of-Hospital Expenses Benefit (OHEB) or a Threshold Benefit
ultimax
BENEFIT
Appliances, external accessories and orthotics
ultima 200
LIMIT PER FAMILY PER YEAR
R13 300 per family per year before and after Threshold.
(R3 710 sub-limit for foot orthotics).
Subject to Savings, OHEB and Threshold
Subject to Savings
Alternative healthcare
Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication)
Subject to Savings and OHEB. Does not accumulate to or pay from
Threshold
Subject to Savings
R14 900 per family per year before and after Threshold.
Subject to Savings, OHEB and Threshold
Subject to Savings
Additional medical services
Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy
Dentistry (Advanced)
Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment
Optometry
R6 250 per beneficiary per year, R12 500 per family per year before
and after Threshold (R1 370 sub-limit per frame).
Subject to Savings, OHEB and Threshold
Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations
Biokinetics, Chiropractics, Dentistry (Basic), Radiology (General), Pathology and Physiotherapy
Subject to Savings
Subject to Savings
Subject to Savings, OHEB and Threshold.
Unlimited once Threshold is reached
Subject to Savings
ultima options Ultimax and Ultima 200
[ 6
day-to-day benefit
(contnued)
ultimax
ultima 200
BENEFIT
LIMIT PER FAMILY PER YEAR
General Practitioners
- Fedhealth Network GPs
Subject to OHEB then unlimited from Risk
Subject to Savings
- Non-Fedhealth Network GPs
Subject to Savings, OHEB and Threshold.
Unlimited once Threshold is reached
Subject to Savings
2 x 2D antenatal scans per year before and after Threshold.
Subject to Savings, OHEB and Threshold
Subject to Savings
Subject to Savings only. Does not accumulate to or
pay from Threshold
Subject to Savings
Maternity
Over-the-counter medication
Prescribed medication
R8 520 per beneficiary per year,
R16 900 per family per year before and after Threshold.
Subject to Savings, OHEB and Threshold
Radiology (Specialised)
Subject to Savings
Paid from the Major Medical Benefit if pre-authorised
Specialists excluding psychiatrists
- Fedhealth Network Specialists
- Non-Fedhealth Network Specialists
Specialists: Psychiatrists
- Fedhealth Network Psychiatrists
- Non-Fedhealth Network Psychiatrists
Subject to Savings, OHEB and
accumulation at cost to Threshold.
Unlimited at cost once Threshold is reached
Subject to Savings
Subject to Savings, OHEB and Threshold.
Unlimited accumulation to and refund from Threshold at FR
Subject to Savings
Subject to Additional Medical Services limit of R14 900 per family
per year before and after Threshold. Subject to Savings,
OHEB and accumulation at cost to Threshold
Subject to Savings
Subject to Additional Medical Services limit of R14 900 per family
per year before and after Threshold. Subject to Savings, OHEB and
Threshold. Accumulation to and refund from Threshold at FR only
Subject to Savings
FR - Fedhealth Rate
OHEB - Out-of-Hospital Expenses Benefit
THRESHOLD BENEFIT
The Threshold Benefit pays for certain day-to-day expenses once Savings and OHEB
have been depleted and claims have accumulated up to the required level. The Threshold Level is reached through the accumulation of claims paid from Savings, OHEB and
the member’s own pocket through the year at the Fedhealth Rate, unless otherwise
specified. Where limits apply, expenses will only accumulate up to this limit and this
limit will also apply to refunds from Threshold. Ultima 200 does not have OHEB or a
Threshold Benefit.
[ 7
the benefits that set us apart
What sets us apart is that together with our first-rate medical aid options, we offer unique value-added
benefits. With some of these tangible benefits we pay more from Risk than other schemes to ensure that
members’ day-to-day medical spending not only goes further, but also works harder when they really need it.
Benefits unique to Fedhealth:
• Unlimited GP visits to Network GPs paid from Risk and never from Savings on the Ultimax option. This benefit
does not apply to Ultima 200
• Child rates for financially dependent children up to 27 years of age – so student dependants pay rates
applicable to children, provided they’re unmarried and not earning more than the maximum social pension
• Upgrades to higher options any time of the year within 30 days of diagnosis of a dread disease, or in the case
of a life changing event – which means the member’s never locked into an option, and can upgrade should
something dramatic happen that changes their circumstances during the year. *New contributions will apply
Where we pay more from Risk than other schemes:
• Post-hospitalisation treatment for up to 30 days after discharge from hospital (physiotherapy, pathology,
occupational therapy, speech therapy and general radiology) – that means most follow-up treatment for a full
30-day period paid directly from Risk not to deplete the member’s day-to-day benefit
• 7 days of take-home medication after discharge from hospital paid for – provided the medication is dispensed
by the hospital and reflects on the original hospital account
• Specialised radiology like MRI and CT scans - paid from Risk and never from Savings – no matter what option
the member’s on, whether performed in or out-of-hospital
• Trauma treatment at a casualty ward - whether admitted to hospital or not, emergency treatment, like
stitches, is always paid from Risk and never from the member’s day-to-day benefit
• Cover for female contraception - including oral, patches, certain injectables as well as IUDs that include
Mirena®, contraceptive rings and implants on all comprehensive options. *Must be prescribed by a GP or
gynaecologist and not applicable to pills prescribed for acne
• The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual
flu vaccine funded from Risk and not from the member’s day-to-day benefit. This benefit even includes
screening and preventative programmes for older members as well.
How we add value:
•The Fedhealth Baby Programme
•24-Hour Fedhealth Nurseline
•FREE trauma counselling for practical and emotional support
•Emergency transport/ response through Europ Assistance
•Comprehensive managed care programmes:
Aid for AIDS (AfA) for those living with HIV/AIDS,
AsthmaCare ensures that asthma patients still lead a normal life,
DiabeticCare assists diabetics in managing their blood sugar,
CardioCare to prevent heart attacks in Coronary Heart Disease
sufferers, and Oncology Disease Management that supports cancer
sufferers with comprehensive care including cover for chemotherapy,
radiotherapy, approved medication, related consultations, pathology
and general radiology.
And then members still get:
• Professional and extreme sports cover - injuries sustained during sporting activities are covered within the
benefits and rules of the Scheme, provided the treatment is received within the borders of South Africa
• In-hospital dentistry for children under 8 - we cover the hospital and anaesthetist costs from the Major
Medical Benefit while the dentist’s account comes from day-to-day benefits (OHEB and Savings) on Ultimax and
Savings only on Ultima 200.
*The Authorisation Centre must be contacted at least 48 hours before the procedure. Authorisation will be
granted provided no dental authorisation was granted for the same child within at least six months of the
required admission date
• Easy membership for child dependants - who are at an age and status to afford their own medical aid,
meaning no underwriting required for child dependants moving from their parent’s medical aid onto their
own at Fedhealth.
contributions
[ 8
contributions
healthcare spending
Rand amounts paid monthly to the Scheme for cover received as well as annual benefit values
Examples of healthcare spend available for various family structures, as well as annual Threshold levels and self-payment gaps
ultimax (including Savings and OHEB)
Member
Adult Dependant
Child Dependant
Risk
Savings
TOTAL
Annual Threshold*
Annual OHEB
7 066
6 002
2 119
389
330
116
7 455
6 332
2 235
11 900
9 020
3 010
2 430
1 380
0
M
M + AD
M + AD + CD
Annual Savings
Annual OHEB
Annual Day-to-Day
Annual Threshold Level
Annual Self- Payment Gap
4 668
8 628
10 020
2 430
3 810
3 810
7 098
12 438
13 830
11 900
20 920
23 930
4 802
8 482
10 100
ultima 200 (including Savings)
Member
Adult Dependant
Child Dependant
Risk
Savings
TOTAL
2 366
2 006
705
27
23
7
2 393
2 029
712
* Up to a maximum of three children
Annual Savings
M
M + AD
M + AD + CD
324
600
684
M - member AD - adult dependant CD - child dependant