Compcare All Plan Comparison 2015

Transcription

Compcare All Plan Comparison 2015
Benefits
Axis - 2015
Axis ED - 2015
Plan Type
Hospital Plan
Plan Operation - Hospitalisation 100% of Agreed Tariff
Hospital Plan
100% of Agreed Tariff
- Day-to-day
Limited post operative rehabilitation benefit
Limited post operative rehabilitation benefit
Overall Annual Maximum
Hospital Benefit
Unlimited
Unlimited
1 Private Hospital Care
Any Private Hospital
2 Co-payment
3 Oncology
Certain procedures, Endoscopies and Scans (R1000 to
R8000)
OAL and Protocols apply. R112 360 for Biological agents
(25% co-pay)
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to 7 days supply per event
DSP. 21 days p/f. Rehabilitation for PMB's only
4 Organ Transplants
5 Dialysis
6 Maternity - Natural Birth
- Elective Ceasarean
7 To take home medication
8 Psychiatric Hospitalisation
Radiology/Pathology/Prosthesis
1 Basic Radiology
Unlimited, subject to protocols
2 MRI, CT & PET Scans
Limited to R15 170 per family
3 Pathology
Limited to R25 170 p/f, unless otherwise authorised
4 Internal Prosthesis
PMB's only. Protocols apply
5 External
No benefit
Appliances/Prosthesis
Sub Acute Facilities
1 Hospice
Unlimited, case management/protocols/pre-auth.
2 Nursing
No benefit
3 Ambulance Services
Unlimited
Chronic Benefit
27 CDL chronic conditions
Unlimited - DSP (Mediscor) and Formulary applies
Netcare hospitals only/ 30% co-pay with R5000 minimum at
others (except emergencies)
Certain procedures, Endoscopies and Scans (R1000 to
R8000)
OAL and Protocols apply. R112 360 for Biological agents
(25% co-pay)
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to 7 days supply per event
DSP. 21 days p/f. Rehabilitation for PMB's only
Dynamix - 2015
Hybrid - Savings and Traditional combined
100% of Agreed Tariff
MSA, AFB ( Annual Flexi Benefit - AFB), Self Payment Gap,
and ATB
Unlimited
Any Private Hospital
Certain procedures, Endoscopies and Scans (R1000 - R2000)
Unlimited. Protocols apply. R168 540 for Biological agents
(25% co-pay)
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to 7 days supply per event
DSP. 21 days p/f. Rehabilitation for PMB's only
Unlimited, subject to protocols
Limited to R15 170 per family
Limited to R25 170 p/f, unless otherwise authorised
PMB's only. Protocols apply
Unlimited, subject to protocols
Unlimited, first R2 250 paid from savings (with accumulation)
Unlimited, subject to protocols
Protocols and various limits apply
No benefit
R17 640 p/f, subject to sublimits, paid from Risk
Unlimited, case management/protocols/pre-auth.
No benefit
Unlimited
Unlimited, case management/protocols/pre-auth.
MSA & AFB apply, in lieu of hospitalisation
Unlimited
Unlimited - DSP (Mediscor) and Formulary applies
Unlimited - DSP (Mediscor) and Formulary applies
36 conditions: M R7 570, M1+ R12 625. Paid from MSA and
AFB, ATB of R2520
Additional chronic conditions
No benefit
No benefit
Day-to-day Benefit
Overall Annual Maximum
Only post operative rehab, limited to R2750/14 days
Only post operative rehab, limited to R2750/14 days
Preferred Provider
N/a
N/a
Medical Savings Account
N/a
N/a
Annual Threshold
Self Payment Gap
Above Threshold Benefit
GP's and medication
1 General Practitioners
2 Specialists
3 Prescribed Medication
4 Pharmacy Advised Medicine
Radiology & Pathology
1 Basic Radiology
2 MRI, CT & PET Scans
3 Pathology
Dental Benefit
1 Conservative Dentistry
2 Specialised Dentistry
Optical Benefit
1 Examination
2 Lenses
3 Frames
4 Contact Lenses
Auxilliary Services
1 Physiotherapy
2 Psychiatry
3 Psychology
HIV / AIDS
Financial and Demographic
1 Date of information
2 Principal Members
3 Administrator
4 Scheme (Option) age profile
5 Solvency ratio
6 Past Scheme increases
Contributions
N/a
N/a
N/a
N/a
N/a
N/a
15% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB
Any GP, Specialist. 10% credit to AFB for use of Network
Providers
15%(Member)+5%(Scheme) - PM: R7704, AD: R6024, C:
R2232
PM: R10 620, AD: R8286, C: R3050
PM: R2916, AD: R2262, C: R818
R5055 p/b and R10 110 p/f, & specified sublimits
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
Subject to MSA, AFB and ATB - unlimited in ATB
100% - Subject to MSA, AFB & ATB. ATB limit: R3275 p/f
Subject to MSA, AFB & ATB. ATB limit: R2520 p/f
R170 per script, limited to: Single R730, Family R1070
No benefit
Combined with In-hospital limit
No benefit
No benefit
Combined with In-hospital limit
No benefit
Subject to MSA, AFB and ATB - ATB limit : R2520 p/f
Combined with In-hospital limit
Combined with Radiology benefit
No benefit
No benefit
No benefit
No benefit
Subject to MSA, AFB and ATB - Unlimited
Subject to MSA & AFB, Limits: M R9 530, M1+ R13 260
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
Subject to MSA, 2 consultations p/b per annum
Subject to MSA and AFB and R3 030 p/b/p/a
Combined with Lenses benefit, R1270 sublimit
Included in Lenses benefit limit
No benefit
No benefit
No benefit
Unlimited, registration recommended
No benefit
No benefit
No benefit
Unlimited, registration recommended
Subject to MSA, AFB & ATB - R1640 limit per family
Subject to MSA & AFB - R8 200 limit p/f
Subject to MSA & AFB - R1910 limit p/f
Unlimited, registration recommended
December 31, 2013
Scheme - 12 610 Axis Options - 783
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(43.0); Pensioner %- 12.7%(17.8%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
December 31, 2013
Scheme - 12 610 Axis Options - 783
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(43.0); Pensioner %- 12.7%(17.8%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
December 31, 2013
Scheme - 12 610 Dynamix Options - 1 586
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(44.6); Pensioner %- 12.7%(21.7%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
Salary Brackets
All
All
All
Principal Member
1436
1077
3323
Principal Member + Spouse
2872
2154
5920
Principal + Spouse + 1 Child
3316
2493
6849
Principal + Spouse + 2 Children 3760
2832
7778
Principal + Spouse + 3 Children 4204
3171
8707
E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.
Benefits
Dynamix ED - 2015
Mumed - 2015
Mumed ED - 2015
Plan Type
Hybrid - Savings and Traditional combined
Traditional limited
Traditional limited
Plan Operation - Hospitalisation 100% of Agreed Tariff
100% of Agreed Tariff
100% of Agreed Tariff
- Day-to-day
MSA, AFB ( Annual Flexi Benefit - AFB) and ATB
Limited to AFB ( Annual Flexi Benefit - AFB)
Limited to AFB ( Annual Flexi Benefit - AFB)
Overall Annual Maximum
Unlimited
R1.5 million per family
R1.5 million per family
Hospital Benefit
Netcare hospitals only/ 30% co-pay with R5000 minimum
Netcare hospitals only/ 30% co-pay with R5000 minimum at
1 Private Hospital Care
Any Private Hospital
at others (except emergencies)
others (except emergencies)
Certain procedures, Endoscopies and Scans (R1000 2 Co-payment
Certain procedures, Endoscopies and Scans (R1000 to R8000) Certain procedures, Endoscopies and Scans (R1000 to R8000)
R2000)
Unlimited. Protocols apply. R168 540 for Biological
OAL and Protocols apply. R112 360 for Biological agents
OAL and Protocols apply. R112 360 for Biological agents
3 Oncology
agents (25% co-pay)
(25% co-pay)
(25% co-pay)
4 Organ Transplants
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
5 Dialysis
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
6 Maternity - Natural Birth
Limited to 3 days and 2 nights
Limited to 3 days and 2 nights
Limited to 3 days and 2 nights
- Elective Ceasarean
Limited to 4 days and 3 nights
Limited to 4 days and 3 nights
Limited to 4 days and 3 nights
7 To take home medication
Limited to 7 days supply per event
Limited to 7 days supply per event
Limited to 7 days supply per event
8 Psychiatric Hospitalisation
DSP. 21 days p/f. Rehabilitation for PMB's only
DSP. 21 days p/f. Rehabilitation for PMB's only
DSP. 21 days p/f. Rehabilitation for PMB's only
Radiology/Pathology/Prosthesis
1 Basic Radiology
Unlimited, subject to protocols
R25 840 per family, subject to OAL
R25 840 per family, subject to OAL
Unlimited, first R2 250 paid from savings (with
2 MRI, CT & PET Scans
Limited to R13 100 per family
Limited to R13 100 per family
accumulation)
3 Pathology
Unlimited, subject to protocols
R19 550 per family, subject to OAL
R19 550 per family, subject to OAL
4 Internal Prosthesis
Protocols and various limits apply
Protocols and various limits apply
Protocols and various limits apply
5 External
R17 640 p/f, subject to sublimits, paid from Risk
R6 850 p/f, subject to sublimits, paid from Risk
R6 850 p/f, subject to sublimits, paid from Risk
Appliances/Prosthesis
Sub Acute Facilities
1 Hospice
Unlimited, case management/protocols/pre-auth.
Unlimited, case management/protocols/pre-auth.
Unlimited, case management/protocols/pre-auth.
2 Nursing
MSA & AFB apply, in lieu of hospitalisation
MSA & AFB apply, in lieu of hospitalisation
MSA & AFB apply, in lieu of hospitalisation
3 Ambulance Services
Unlimited
Unlimited
Unlimited
Chronic Benefit
27 CDL chronic conditions
Unlimited - DSP (Mediscor) and Formulary applies
Unlimited - DSP (Mediscor) and Formulary applies
Unlimited - DSP (Mediscor) and Formulary applies
36 conditions: M R7 570, M1+ R12 625. Paid from MSA
Additional chronic conditions
No benefit
No benefit
and AFB, ATB of R2520
Day-to-day Benefit
Overall Annual Maximum
18% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB AFB - PM: R4944, AD: R3096, C: R1236
AFB - PM: R4944, AD: R3096, C: R1236
Any GP, Specialist. 10% credit to AFB for use of Network Any GP, Specialist. 10% credit to AFB for use of Network
Any GP, Specialist. 10% credit to AFB for use of Network
Preferred Provider
Providers
Providers
Providers
15%(Member)+5%(Scheme) - PM: R7704, AD: R6024,
Medical Savings Account
N/a
N/a
C: R2232
Annual Threshold
PM: R10 620, AD: R8286, C: R3050
N/a
N/a
Self Payment Gap
PM: R2916, AD: R2262, C: R818
N/a
N/a
Above Threshold Benefit
R5055 p/b and R10 110 p/f, & specified sublimits
N/a
N/a
GP's and medication
1 General Practitioners
Subject to MSA, AFB and ATB - unlimited in ATB
OAL: M 6 visits, M1 8 visits, M2 10 visits, M3+ 11 visits
OAL: M 6 visits, M1 8 visits, M2 10 visits, M3+ 11 visits
2 Specialists
100% - Subject to MSA, AFB & ATB. ATB limit: R3275 p/f Subject to AFB limit
Subject to AFB limit
3 Prescribed Medication
Subject to MSA, AFB & ATB. ATB limit: R2520 p/f
Subject to AFB limit and Formulary
Subject to AFB limit and Formulary
4 Pharmacy Advised Medicine R170 per script, limited to: Single R730, Family R1070
R145 per script, limited to: Single R490, Family R865
R145 per script, limited to: Single R490, Family R865
Radiology & Pathology
1 Basic Radiology
Subject to MSA, AFB and ATB - ATB limit : R2520 p/f
Subject to AFB limit
Subject to AFB limit
2 MRI, CT & PET Scans
Combined with In-hospital limit
Combined with In-hospital limit
Combined with In-hospital limit
3 Pathology
Combined with Radiology benefit
Subject to AFB limit
Subject to AFB limit
Dental Benefit
1 Conservative Dentistry
Subject to MSA, AFB and ATB - Unlimited
Subject to AFB limit, thereafter unlimited
Subject to AFB limit, thereafter unlimited
2 Specialised Dentistry
Subject to MSA & AFB, Limits: M R9 530, M1+ R13 260 Subject to AFB limit: Limited to R1700 p/b
Subject to AFB limit: Limited to R1700 p/b
Optical Benefit
1 Examination
Subject to MSA, 2 consultations p/b per annum
MSA & AFB, 1 consultation p/b per annum
MSA & AFB, 1 consultation p/b per annum
2 Lenses
Subject to MSA and AFB and R3 030 p/b/p/a
Subject to AFB limit, sublimit of R1315 p/b and R3795 p/f
Subject to AFB limit, sublimit of R1315 p/b and R3795 p/f
3 Frames
Combined with Lenses benefit, R1270 sublimit
Combined with Lenses benefit, R660 sublimit
Combined with Lenses benefit, R660 sublimit
4 Contact Lenses
Included in Lenses benefit limit
Included in Lenses benefit limit
Included in Lenses benefit limit
Auxilliary Services
1 Physiotherapy
Subject to MSA, AFB & ATB - R1640 limit per family
Subject to AFB limit : R1645 p/b and R2615 p/f
Subject to AFB limit : R1645 p/b and R2615 p/f
2 Psychiatry
Subject to MSA & AFB - R8 200 limit p/f
Subject to AFB limit : R3 455 p/f
Subject to AFB limit : R3 455 p/f
3 Psychology
Subject to MSA & AFB - R1910 limit p/f
Subject to AFB limit : R1 375 p/b and R3 455 p/f sublimit
Subject to AFB limit : R1 375 p/b and R3 455 p/f sublimit
HIV / AIDS
Unlimited, registration recommended
Unlimited, registration recommended
Unlimited, registration recommended
Financial and Demographic
1 Date of information
December 31, 2013
December 31, 2013
December 31, 2013
2 Principal Members
Scheme - 12 610 Dynamix Options - 1 586
Scheme - 12 610 Mumed Options - 3 049
Scheme - 12 610 Mumed Options - 3 049
3 Administrator
Universal Healthcare Administrators (Pty) Ltd
Universal Healthcare Administrators (Pty) Ltd
Universal Healthcare Administrators (Pty) Ltd
4 Scheme (Option) age profile Average age- 37.1(44.6); Pensioner %- 12.7%(21.7%)
Average age- 37.1(32.7); Pensioner %- 12.7%(7.4%)
Average age- 37.1(32.7); Pensioner %- 12.7%(7.4%)
5 Solvency ratio
42.10%
42.10%
42.10%
6 Past Scheme increases
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
Contributions
All
R0
R6000
R6001
R7900
R7901
R15000
Principal Member
2815
Principal Member + Spouse
5012
1563
1731
1886
2097
2774
3082
3357
3731
Principal + Spouse + 1 Child
5800
3217
3575
3892
Principal + Spouse + 2 Children 6588
3660
4068
Principal + Spouse + 3 Children 7376
4103
4561
Salary Brackets
R15001+
R0
R6000
R6001
R7900
R7901
R15000
1296
1429
1548
1717
2296
2534
2759
3054
4322
2662
2942
3195
3533
4427
4913
3028
3350
3631
4012
4962
5504
3394
3758
4067
4491
E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.
R15001+
Benefits
Mumed ED Network - 2015
Plan Type
Capitation (Designated Service Providers)
Plan Operation - Hospitalisation 100% of Agreed Tariff
- Day-to-day
Limited to AFB ( Annual Flexi Benefit - AFB)
Overall Annual Maximum
R1.5 million per family
Hospital Benefit
Netcare hospitals only/ 30% co-pay with R5000
1 Private Hospital Care
minimum at others (except emergencies)
Certain procedures, Endoscopies and Scans (R1000
2 Co-payment
to R8000)
OAL and Protocols apply. R112 360 for Biological
3 Oncology
agents (25% co-pay)
4 Organ Transplants
Limited to PMB conditions at DSP
5 Dialysis
Limited to PMB conditions at DSP
6 Maternity - Natural Birth
Limited to 3 days and 2 nights
- Elective Ceasarean
Limited to 4 days and 3 nights
7 To take home medication
Limited to 7 days supply per event
8 Psychiatric Hospitalisation
DSP. 21 days p/f. Rehabilitation for PMB's only
Radiology/Pathology/Prosthesis
1 Basic Radiology
R25 840 per family, subject to OAL
2 MRI, CT & PET Scans
Limited to R13 100 per family
3 Pathology
R19 550 per family, subject to OAL
4 Internal Prosthesis
Protocols and various limits apply
5 External
R6 850 p/f, subject to sublimits, paid from Risk
Appliances/Prosthesis
Sub Acute Facilities
1 Hospice
Unlimited, case management/protocols/pre-auth.
2 Nursing
MSA & AFB apply, in lieu of hospitalisation
3 Ambulance Services
Unlimited
Chronic Benefit
27 CDL chronic conditions
Unlimited - DSP (Mediscor) and Formulary applies
Additional chronic conditions
No benefit
Day-to-day Benefit
Overall Annual Maximum
AFB - PM: R4944, AD: R3096, C: R1236
Any GP, Specialist. 10% credit to AFB for use of
Preferred Provider
Network Providers
Medical Savings Account
N/a
Annual Threshold
N/a
Self Payment Gap
N/a
Above Threshold Benefit
N/a
GP's and medication
NetworX - 2015
NetworX ED - 2015
Capitation (Designated Service Providers)
100% of Agreed Tariff
Designated Service Providers & set limits
R1 000 000 per family
Capitation (Designated Service Providers)
100% of Agreed Tariff
Designated Service Providers & set limits
R1 000 000 per family
Any Private Hospital
Public Hospitals only. No benefit for Private facilities
None
None
PMB's only, subject to OAL and protocols
PMB's only, subject to protocols
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to R250 per discharge at DSP Hospital
21 days p/f at DSP. Rehabilitation for PMB's only
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to R250 per discharge at DSP Hospital
21 days p/f at DSP. Rehabilitation for PMB's only
Unlimited, subject to case management, protocols
AOL applies, subject to protocols
Unlimited, subject to case management, protocols, DSP
PMB's only. Protocols apply
Unlimited, subject to case management, protocols
AOL applies, subject to protocols
Unlimited, subject to case management, protocols, DSP
PMB's only. Protocols apply
PMB's only
PMB's only
Limited to OAL, case management/protocols/pre-auth.
No benefit
Unlimited
Limited to OAL, case management/protocols/pre-auth.
No benefit
Unlimited
Unlimited - DSP (Mediscor) and Formulary applies
No benefit
Unlimited - DSP (Mediscor) and Formulary applies
No benefit
Annual Flexi Benefit: Single R2532, Family R3780
Member must select from a list of contracted GP provider
network
N/a
N/a
N/a
N/a
Annual Flexi Benefit: Single R2532, Family R3780
Member must select from a list of contracted GP provider
network
N/a
N/a
N/a
N/a
Unlimited : Subject to DSP GP. 2 non DSP visits p/b - R900 per
event, 20% co-payment
Subject to AFB limit, 2 visits p/b & 3 p/f, on referral
Unlimited if prescribed by DSP GP, Formulary applies
No benefit
1 General Practitioners
OAL: M 6 visits, M1 8 visits, M2 10 visits, M3+ 11 visits
2 Specialists
3 Prescribed Medication
4 Pharmacy Advised Medicine
Radiology & Pathology
1 Basic Radiology
2 MRI, CT & PET Scans
3 Pathology
Dental Benefit
1 Conservative Dentistry
2 Specialised Dentistry
Optical Benefit
1 Examination
Subject to AFB limit
Subject to AFB limit and Formulary
R145 per script, limited to: Single R490, Family R865
Unlimited : Subject to DSP GP. 2 non DSP visits p/b - R900 per
event, 20% co-payment
Subject to AFB limit, 2 visits p/b & 3 p/f, on referral
Unlimited if prescribed by DSP GP, Formulary applies
No benefit
Subject to AFB limit
Combined with In-hospital limit
Subject to AFB limit
Specific list of black & white x-rays, subject to referral
No benefit, except PMB's
PMB's only at DSP (GP referral)
Specific list of black & white x-rays, subject to referral
No benefit, except PMB's
PMB's only at DSP (GP referral)
Subject to AFB limit, thereafter unlimited
Subject to AFB limit: Limited to R1700 p/b
Subject to AFB: PMB's only
Subject to AFB limit: PMB's only
Subject to AFB: PMB's only
Subject to AFB limit: PMB's only
MSA & AFB, 1 consultation p/b per annum
Subject to AFB limit, sublimit of R1315 p/b and R3795
p/f
Combined with Lenses benefit, R660 sublimit
Included in Lenses benefit limit
Subject to AFB limit: One consultation p/b per 24 months
Subject to AFB limit: One consultation p/b per 24 months
Single vision R695 p/b, or bifocal R1113 p/b x 24 mths
Single vision R695 p/b, or bifocal R1113 p/b x 24 mths
Limited range within DSP network
No benefit
Limited range within DSP network
No benefit
Subject to AFB limit : R1645 p/b and R2615 p/f
Subject to AFB limit : R3 455 p/f
Subject to AFB limit : R1 375 p/b and R3 455 p/f
sublimit
Unlimited, registration recommended
No benefit
No benefit
No benefit
No benefit
No benefit
No benefit
Unlimited, registration recommended
Unlimited, registration recommended
December 31, 2013
Scheme - 12 610 Mumed Options - 3 049
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(32.7); Pensioner %- 12.7%(7.4%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
December 31, 2013
Scheme - 12 610 NetworX Options - 3 337
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(24.5); Pensioner %- 12.7%(0.5%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
December 31, 2013
Scheme - 12 610 NetworX Options - 3 337
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(24.5); Pensioner %- 12.7%(0.5%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
2 Lenses
3 Frames
4 Contact Lenses
Auxilliary Services
1 Physiotherapy
2 Psychiatry
3 Psychology
HIV / AIDS
Financial and Demographic
1 Date of information
2 Principal Members
3 Administrator
4 Scheme (Option) age profile
5 Solvency ratio
6 Past Scheme increases
Contributions
Salary Brackets
R0
R7900
R7901
R15000
R15001+
R0
R500
R501
R4000
Principal Member
1212
1321
1469
325
540
Principal Member + Spouse
2158
2351
2612
650
1020
1053
Principal + Spouse + 1 Child
2504
2727
3027
808
1203
1242
Principal + Spouse + 2 Children 2850
3103
3442
966
1386
1431
Principal + Spouse + 3 Children 3196
3479
3857
1124
523
1569
R4001
R5000
1620
R5001
R6000
R6001
R8000
R0
R500
646
676
310
1259
1319
616
699
881
1486
1556
784
873
1096
1713
1793
952
1047
2030
1120
1940
R501
R4000
353
1221
E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.
R4001
R6000
452
1311
1526
R6001
R9000
539
1051
1307
1563
1819
R9001
R10000
571
1114
1386
1658
1930
Benefits
Pinnacle - 2015
Plan Type
New Generation with Threshold
Plan Operation - Hospitalisation 100% of Agreed Tariff, 200% Specialist cover
MSA, AFB ( Annual Flexi Benefit - AFB), Self Payment Gap,
- Day-to-day
and ATB
Overall Annual Maximum
Unlimited
Hospital Benefit
Pinnacle ED - 2015
New Generation with Threshold
100% of Agreed Tariff, 200% Specialist cover
MSA, AFB ( Annual Flexi Benefit - AFB), Self Payment Gap,
and ATB
Unlimited
Netcare hospitals only/ 30% co-pay with R5000 minimum at
others (except emergencies)
1 Private Hospital Care
Any Private Hospital
2 Co-payment
Certain procedures, Endoscopies and Scans (R1000 - R2000) Certain procedures, Endoscopies and Scans (R1000 - R2000)
3 Oncology
Unlimited. Protocols apply. R224 720 for Biological agents
4 Organ Transplants
Limited to PMB conditions at DSP
5 Dialysis
Limited to PMB conditions at DSP
6 Maternity - Natural Birth
Limited to 3 days and 2 nights
- Elective Ceasarean
Limited to 4 days and 3 nights
7 To take home medication
Limited to 7 days supply per event
8 Psychiatric Hospitalisation
DSP. 21 days p/f. Rehabilitation for PMB's only
Radiology/Pathology/Prosthesis
1 Basic Radiology
Unlimited, subject to protocols
2 MRI, CT & PET Scans
Unlimited, first R2 250 paid from savings (with accumulation)
3 Pathology
Unlimited, subject to protocols
4 Internal Prosthesis
Protocols and various limits apply
5 External
R56 180 p/f, subject to sublimits, paid from Risk
Appliances/Prosthesis
Sub Acute Facilities
1 Hospice
Unlimited, case management/protocols/pre-auth.
2 Nursing
MSA & AFB apply, in lieu of hospitalisation
3 Ambulance Services
Unlimited
Chronic Benefit
27 CDL chronic conditions
Unlimited - DSP (Mediscor) and Formulary applies
45 conditions: M R10 090, M1+ R15 150. Paid from MSA and
Additional chronic conditions
AFB, ATB of R3785
Day-to-day Benefit
Overall Annual Maximum
20% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB
Any GP, Specialist. 10% credit to AFB for use of Network
Preferred Provider
Providers
20%(Member)+5%(Scheme) - PM: R12 900, AD: R10 068, C:
Medical Savings Account
R3540
Annual Threshold
PM: R14 208, AD: R11 043, C: R3 857
Self Payment Gap
PM: R1303, AD: R975, C: R317
Above Threshold Benefit
R7525 p/b and R15 135 p/f, & specified sublimits
GP's and medication
1 General Practitioners
Subject to MSA, AFB and ATB - unlimited in ATB
2 Specialists
200% - Subject to MSA, AFB & ATB. ATB limit: R3785 p/f
3 Prescribed Medication
Subject to MSA, AFB & ATB. ATB limit: R3150 p/f
4 Pharmacy Advised Medicine R180 per script, limited to: Single R840, Family R1190
Radiology & Pathology
1 Basic Radiology
R3785 p/f, Subject to MSA, AFB and ATB
2 MRI, CT & PET Scans
Combined with In-hospital limit
3 Pathology
Combined with Radiology benefit
Dental Benefit
1 Conservative Dentistry
Subject to MSA, AFB and ATB - Unlimited
2 Specialised Dentistry
Subject to MSA and AFB - R14 575 p/b sublimit
Optical Benefit
1 Examination
MSA & AFB, 2 consultations p/b per annum
2 Lenses
Subject to MSA and ATB - R3 785 p/b
3 Frames
Combined with Lenses benefit, R1910 sublimit
4 Contact Lenses
Included in Lenses benefit limit
Auxilliary Services
1 Physiotherapy
Subject to MSA, AFB and ATB - R2530 limit p/f
2 Psychiatry
Subject to MSA and ATB - R13 885 limit p/f
3 Psychology
Subject to MSA and ATB - R4155 limit p/f
HIV / AIDS
Unlimited, registration recommended
Financial and Demographic
1 Date of information
December 31, 2013
2 Principal Members
Scheme - 12 610 Pinnacle Options - 1 134
3 Administrator
Universal Healthcare Administrators (Pty) Ltd
4 Scheme (Option) age profile Average age- 37.1(47.5); Pensioner %- 12.7%(22.8%)
5 Solvency ratio
42.10%
6 Past Scheme increases
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
Contributions
Symmetry - 2015
Traditional limited
100% of Agreed Tariff
Limited to AFB ( Annual Flexi Benefit - AFB)
Unlimited
Any Private Hospital
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to 7 days supply per event
DSP. 21 days p/f. Rehabilitation for PMB's only
Certain procedures, Endoscopies and Scans (R1000 to
R4000)
Unlimited. Protocols apply. R112 360 for Biological agents
(25% co-pay)
Limited to PMB conditions at DSP
Limited to PMB conditions at DSP
Limited to 3 days and 2 nights
Limited to 4 days and 3 nights
Limited to 7 days supply per event
DSP. 21 days p/f. Rehabilitation for PMB's only
Unlimited, subject to protocols
Unlimited, first R2 250 paid from savings (with accumulation)
Unlimited, subject to protocols
Protocols and various limits apply
Unlimited, subject to protocols
Limited to R15 170 per family
Limited to R25 165 p/f, unless otherwise authorised
Protocols and various limits apply
R56 180 p/f, subject to sublimits, paid from Risk
R13 260 p/f, subject to sublimits, paid from Risk
Unlimited, case management/protocols/pre-auth.
MSA & AFB apply, in lieu of hospitalisation
Unlimited
Unlimited, case management/protocols/pre-auth.
MSA & AFB apply, in lieu of hospitalisation
Unlimited
Unlimited. Protocols apply. R224 720 for Biological agents
Unlimited - DSP (Mediscor) and Formulary applies
Unlimited - DSP (Mediscor) and Formulary applies
45 conditions: M R10 090, M1+ R15 150. Paid from MSA and 19 Conditions - M R3 785, M1+ R5 670. CDL initially paid
AFB, ATB of R3785
from here
20% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB
Any GP, Specialist. 10% credit to AFB for use of Network
Providers
20%(Member)+5%(Scheme) - PM: R12 900, AD: R10 068, C:
R3540
PM: R14 208, AD: R11 043, C: R3 857
PM: R1303, AD: R975, C: R317
R7525 p/b and R15 135 p/f, & specified sublimits
AFB - PM: R6552, AD: R4164, C: R1548
Any GP, Specialist. 10% credit to AFB for use of Network
Providers
Subject to MSA, AFB and ATB - unlimited in ATB
200% - Subject to MSA, AFB & ATB. ATB limit: R3785 p/f
Subject to MSA, AFB & ATB. ATB limit: R3150 p/f
R180 per script, limited to: Single R840, Family R1190
Subject to AFB - Consultations unlimited in ATB
Subject to AFB limit
Subject to AFB limit and Formulary
R145 per script, limited to: Single R595, Family R955
R3785 p/f, Subject to MSA, AFB and ATB
Combined with In-hospital limit
Combined with Radiology benefit
Subject to AFB limit
Combined with In-hospital limit
Subject to AFB limit
Subject to MSA, AFB and ATB - Unlimited
Subject to MSA and AFB - R14 575 p/b sublimit
Subject to AFB limit, thereafter unlimited
Subject to AFB limit: Limited to R6 360 p/b. No implants
MSA & AFB, 2 consultations p/b per annum
Subject to MSA and ATB - R3 785 p/b
Combined with Lenses benefit, R1910 sublimit
Included in Lenses benefit limit
MSA & AFB, 1 consultation p/b per annum
Subject to AFB limit, sublimit of R1700
Combined with Lenses benefit, R900 sublimit
Included in Lenses benefit limit
Subject to MSA, AFB and ATB - R2530 limit p/f
Subject to MSA and ATB - R13 885 limit p/f
Subject to MSA and ATB - R4155 limit p/f
Unlimited, registration recommended
Subject to AFB limit : R2 530 p/b
Subject to AFB limit : R5 280 p/b sublimit
Subject to AFB limit : R1 545 p/b sublimit
Unlimited, registration recommended
December 31, 2013
Scheme - 12 610 Pinnacle Options - 1 134
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(47.5); Pensioner %- 12.7%(22.8%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
December 31, 2013
Scheme - 12 610 Symmetry Options - 2 721
Universal Healthcare Administrators (Pty) Ltd
Average age- 37.1(39.8); Pensioner %- 12.7%(15.4%)
42.10%
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
N/a
N/a
N/a
N/a
Salary Brackets
All
All
All
Principal Member
4412
3780
2640
Principal Member + Spouse
7847
6722
4695
Principal + Spouse + 1 Child
9072
7778
5441
Principal + Spouse + 2 Children 10297
8834
6187
Principal + Spouse + 3 Children 11522
9890
6933
E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.
Benefits
Symmetry ED - 2015
Plan Type
Traditional limited
Plan Operation - Hospitalisation 100% of Agreed Tariff
- Day-to-day
Limited to AFB ( Annual Flexi Benefit - AFB)
Overall Annual Maximum
Unlimited
Hospital Benefit
1 Private Hospital Care
Netcare hospitals only/ 30% co-pay with R5000 minimum at others (except emergencies)
2 Co-payment
Certain procedures, Endoscopies and Scans (R1000 to R4000)
3 Oncology
Unlimited. Protocols apply. R112 360 for Biological agents (25% co-pay)
4 Organ Transplants
Limited to PMB conditions at DSP
5 Dialysis
Limited to PMB conditions at DSP
6 Maternity - Natural Birth
Limited to 3 days and 2 nights
- Elective Ceasarean
Limited to 4 days and 3 nights
7 To take home medication
Limited to 7 days supply per event
8 Psychiatric Hospitalisation
DSP. 21 days p/f. Rehabilitation for PMB's only
Radiology/Pathology/Prosthesis
1 Basic Radiology
Unlimited, subject to protocols
2 MRI, CT & PET Scans
Limited to R15 170 per family
3 Pathology
Limited to R25 165 p/f, unless otherwise authorised
4 Internal Prosthesis
Protocols and various limits apply
5 External
R13 260 p/f, subject to sublimits, paid from Risk
Appliances/Prosthesis
Sub Acute Facilities
1 Hospice
Unlimited, case management/protocols/pre-auth.
2 Nursing
MSA & AFB apply, in lieu of hospitalisation
3 Ambulance Services
Unlimited
Chronic Benefit
27 CDL chronic conditions
Unlimited - DSP (Mediscor) and Formulary applies
Additional chronic conditions
19 Conditions - M R3 785, M1+ R5 670. CDL initially paid from here
Day-to-day Benefit
Overall Annual Maximum
AFB - PM: R6552, AD: R4164, C: R1548
Preferred Provider
Any GP, Specialist. 10% credit to AFB for use of Network Providers
Medical Savings Account
N/a
Annual Threshold
N/a
Self Payment Gap
N/a
Above Threshold Benefit
N/a
GP's and medication
1 General Practitioners
Subject to AFB - Consultations unlimited in ATB
2 Specialists
Subject to AFB limit
3 Prescribed Medication
Subject to AFB limit and Formulary
4 Pharmacy Advised Medicine R145 per script, limited to: Single R595, Family R955
Radiology & Pathology
1 Basic Radiology
Subject to AFB limit
2 MRI, CT & PET Scans
Combined with In-hospital limit
3 Pathology
Subject to AFB limit
Dental Benefit
1 Conservative Dentistry
Subject to AFB limit, thereafter unlimited
2 Specialised Dentistry
Subject to AFB limit: Limited to R6 360 p/b. No implants
Optical Benefit
1 Examination
MSA & AFB, 1 consultation p/b per annum
2 Lenses
Subject to AFB limit, sublimit of R1700
3 Frames
Combined with Lenses benefit, R900 sublimit
4 Contact Lenses
Included in Lenses benefit limit
Auxilliary Services
1 Physiotherapy
Subject to AFB limit : R2 530 p/b
2 Psychiatry
Subject to AFB limit : R5 280 p/b sublimit
3 Psychology
Subject to AFB limit : R1 545 p/b sublimit
HIV / AIDS
Unlimited, registration recommended
Financial and Demographic
1 Date of information
December 31, 2013
2 Principal Members
Scheme - 12 610 Symmetry Options - 2 721
3 Administrator
Universal Healthcare Administrators (Pty) Ltd
4 Scheme (Option) age profile Average age- 37.1(39.8); Pensioner %- 12.7%(15.4%)
5 Solvency ratio
42.10%
6 Past Scheme increases
2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9%
Contributions
Salary Brackets
All
Principal Member
2217
Principal Member + Spouse
3942
Principal + Spouse + 1 Child
4569
Principal + Spouse + 2 Children 5196
Principal + Spouse + 3 Children 5823
E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.