docHow the scheme works ultimax ultima 200 R
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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
