Summary of the benefits available on the Quantum Essential Saver Plan

Transcription

1 Quantum Essential Saver Quantum Essential Saver 2009 Welcome to the Quantum Essential Saver Plan. Please keep this information in a safe place for future reference. Summary of the benefits available on the Quantum Essential Saver Plan Here is a summary of the key features on the Quantum Essential Saver Plan. You can find more information in this brochure. The Hospital Benefit covers you if you are admitted to hospital and the Scheme has confirmed your admission and treatment. You are covered for approved medicine and treatment for 57 chronic conditions, cancer and HIV and AIDS. The Screening Benefit covers a range of preventive screening tests. Your health benefits exclude cover for medical emergencies while travelling in other countries. We pay your day-to-day expenses from the available money in your Medical Savings Account. If you run out of money in your Medical Savings Account, you must pay for your day-to-day medical expenses from your pocket. Contact us All our legal rules are available on request This brochure is merely a summary of the benefits and features of the Quantum Essential Saver Plan. The rules of the Scheme apply to your benefits. If you want to refer to the full set of legal rules on which this brochure is based, please write to: The Fund Manager Quantum Medical Aid Society PO Box Benmore 2010 Get detailed information on the benefits offered by your plan on or ask us for this. If you want to change your plan You can change to any other plan at the end of each year with effect from 1 January the following year, not during the year. Please speak to your HR department before you decide to change your plan.

2 5 General exclusions Quantum Medical Aid Society will not pay for healthcare services related to the following, except as stipulated in the Prescribed Minimum Benefits: Cosmetic procedures and treatments Otoplasty for bat-ears, portwine stains and blepharoplasty (eyelid surgery) Breast reductions and gynaecomastia Obesity Frail care Infertility Alcohol, drug or solvent abuse Wilfully self-inflicted illness or injury Wilful and material participation in a violation of the law or during a period of imprisonment Wilful participation in war, terrorist activity, riot, civil commotion, rebellion or uprising Experimental, unproven or unregistered treatment or practices Search and rescue Any costs for which a third party is legally responsible CT colonoscopy and CT angiogram of the coronary vessels. Quantum Medical Aid Society will cover neither the complications nor the direct or indirect expenses that arise from any of the above. If you have never belonged to a medical scheme or you have had a break in medical scheme membership of more than 90 days before joining Quantum Medical Aid Society, you will not have access to the Prescribed Minimum Benefits during your waiting period(s). This includes cover for emergency admissions. 6 Important tips when claiming When claiming from the Scheme for your medical costs, whether these are hospital, chronic or day-to-day, these steps apply: Send your claims within four months, otherwise we will consider them expired and not pay them When sending claims, please make sure the following details are clear: 1. Your membership number 2. The service date 3. Your doctor s details and practice number 4. The amounts charged 5. The relevant consultation, procedure or NAPPI code and diagnostic (ICD-10) codes 6. The name and birth date of the dependant for whom the service was done 7. If paid, attach your receipt or make sure the claim says paid Remember to always keep copies of your claims for your records To see the status of your claim, you can go to GM_3223DHM_20/03/2009 SFFE 12/08 (09)

3 4 Cover for day-to-day medical expenses (continued) Here is a summary of how we pay your day-to-day medical expenses. This is the maximum amount we will pay for claims. Day-to-day benefit How we pay the claim The annual limit on this benefit (claims paid from your available Medical Savings Account) Professional services General practitioner Specialists Allied health professionals (for example physiotherapists, chiropractors, occupational and speech therapists) Radiology and pathology Mental health benefit (including psychologists and psychiatrists) Private nursing Antenatal classes Pregnancy scans (up to two 2D scans for each pregnancy. 3D scans are covered as 2D scans) Dentistry Endoscopies (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) done in your doctor s rooms or Premier Rate where applicable Up to These expenses are limited to available funds in your Medical Savings Account. There is no limit to these healthcare services. The Scheme pays for these claims without using your Medical Savings Account. Please call us before you have a scope in your doctor s rooms to confirm your benefits. MRI and CT scans (must be referred by an appropriate specialist) There is no limit to these healthcare services. We will pay the first R1 800 of your MRI or CT scan code from available funds in your Medical Savings Account. We cover the balance in full at the Scheme Rate. Medicine Prescribed medicine (schedule 3 and above) We pay up to 100% of the Scheme medication rate. These claims are limited to available funds in your Medical Savings Account. Over-the-counter medicine, including We pay up to the 100% of the Scheme These claims are limited to the available funds in prescribed schedule 0, 1 and 2 medication rate. your Medical Savings Account. medicine and lifestyle-enhancing products Appliances and equipment External medical items These claims are limited to the available funds in Hearing aids Optical (includes cover for spectacles, frames, contact lenses and surgery to correct refractive errors of the eye, for example excimer laser) your Medical Savings Account.

4 1 Cover for medical emergencies What is a medical emergency? A medical emergency is the sudden, unexpected onset of a health condition that needs immediate medical or surgical treatment. If this treatment is not provided, the person s life would be at risk or result in serious impairment or dysfunction of an organ or body part. Cover for medical emergencies in South Africa Discovery 911 is a nationwide group of highly trained paramedics to help you with all aspects of your medical emergency, including trauma counselling. Call Discovery 911 on this number is displayed on your membership card and car sticker for easy reference. If you need medically equipped transport, for example an ambulance or helicopter for a medical emergency, we will cover the costs from your Hospital Benefit, whether you are admitted to hospital or not. Emergency care We will cover your emergency admission in full as a Prescribed Minimum Benefit in whatever hospital you are admitted to. A Prescribed Minimum Benefit is the minimum amount of cover that any medical scheme must offer. Once you have been stabilised we will arrange a transfer to our designated service provider (our choice of hospital provider or healthcare professional) for your cover to continue in full. You may choose to stay in the non-designated service provider hospital and have your claims paid according to your plan type, but you may have to pay an amount. We cover HIV prophylactics If you need HIV prophylactics to prevent HIV infection from mother-to-child transmission, occupational or traumatic exposure to HIV or sexual assault, call us on Cover for going to casualty If you are admitted to hospital from casualty, we will cover the costs of the casualty visit from your Hospital Benefit, as long as we confirm your admission. If you go to a casualty or emergency room and you are not admitted to hospital, we will pay the costs from your day-to-day benefits. Some casualties charge a facility fee, which we do not cover. Cover while travelling overseas Your plan excludes cover for medical emergencies while travelling abroad. However if you incur out-of-hospital or in-hospital medical costs while travelling overseas, you can send these claims upon return. We will refund you at the Scheme Rate if it is for a procedure or claim that would normally be covered under your benefits. You will need to complete the Scheme-specific international claim form when sending these claims. Payment of these claims is at the scheme s discretion. You may buy insurance for baggage or extended medical cover by contacting their travel agent. Cover for evacuation in Africa Your health plan provides cover to the Africa Claims Benefit, but NOT to the Africa Evacuation Benefit. The Africa Claims Benefit is where the Scheme will fund claims outside South Africa at the Scheme Rate if it is for a procedure or claim that would normally be covered under the member s benefits. The member will have to pay for medical expenses upfront and send the claims to the Scheme. Payment of these claims is at the Scheme s discretion. 2 You have extensive and flexible cover for chronic conditions, HIV and AIDS and cancer Chronic Illness Benefit If you are diagnosed with one or more of the Chronic Disease List conditions, you have full cover for approved medicine on our medicine list (formulary) or up to a set amount, called the Chronic Drug Amount for medicine not on our list. You will be responsible for the balance if your medicine costs more than the Chronic Drug Amount. We pay medicine up to a. Please note the medicine list (formulary) and the Chronic Drug Amount may change from time to time. You can find the conditions, medicine list and Chronic Drug Amounts on We need to approve your application We need to approve your application before we cover your condition from the Chronic Illness Benefit. To apply, get an application form on or ask us to send you one. Complete the relevant application form with your doctor and send it to us. We will send you a letter detailing the cover available to you. What we cover as a Prescribed Minimum Benefit We cover the diagnosis, consultations and medicine for 27 chronic conditions (including HIV and AIDS) according to the Prescribed Minimum Benefit treatment guidelines. Additional Cover You have cover for an additional 30 chronic conditions on our Additional Disease List. We pay up to the Chronic Drug Amount for your approved medicine to treat your condition. There is no medicine list (formulary) for the treatment of these conditions. The Chronic Illness Benefit covers a limited number of diagnostic tests and consultations for these conditions. The benefit includes tests and consultations for both the diagnosis and management for each condition. You have cover for treating cancer through our Oncology Programme Our case managers will coordinate your cancer benefits with your treating doctor. We will approve your treatment as long as it is in line with our clinical guidelines. We will send you these treatment guidelines when you register on the Oncology Programme.

5 3 Hospital benefits We cover you in hospital for emergency and planned hospital admissions. In an emergency, go straight to hospital but call us or get someone to call us within 12 hours. For planned hospital admissions, please call us 48 hours before you go to hospital to confirm your admission. Important information about your hospital cover What to do before you go to hospital Before you go to hospital for any planned procedure, you must: Cover for Prescribed Minimum Benefits For Prescribed Minimum Benefits, we pay admissions for approximately 270 defined conditions in full if you have See your doctor treatment at one of our designated service providers (our choice of hospitals or healthcare professionals). If Call us on to confirm your hospital you do not use our designated service provider you may admission at least 48 hours before you go in. If you do not confirm your admission, we will only pay 70% of the costs that we would normally cover. have to pay the difference between what the healthcare professional charges and what the Scheme pays. Cover is subject to our rules We pay medically appropriate claims. Your cover is subject to our Scheme rules, funding guidelines and clinical rules. There are some expenses that you may incur while you are in hospital that your benefit does not cover, for example private ward costs. Certain procedures, medicines or new technologies need separate confirmation while you are in hospital. You can find out more about our clinical rules and policies for cover at A detailed description of how we pay for Prescribed Minimum Benefits is available on How we cover your healthcare professionals Your healthcare professionals accounts are separate from the hospital account. Healthcare professional accounts may include specialist accounts and other related accounts, for example accounts from a surgeon, anaesthetist, pathologist or radiologist. Healthcare professionals are free to set their own rates. If they charge the Scheme Rate or take part in a payment arrangement, we will pay them directly. If they charge more than the Scheme Rate or choose not to take part in a payment arrangement, we will pay you. You will have to make sure you pay your healthcare professionals the full amount. Hospital limits Overall limit Procedures and consultations by specialists taking part in payment arrangements Other healthcare professionals Radiology and pathology (an appropriate medical professional must refer you) Endoscopies (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) MRI and CT scans Dentistry There is no overall hospital limit on the Quantum Essential Saver Plan. The Quantum Essential Saver plan is limited, at. Limits apply to some healthcare services and procedures. We pay your procedures and consultations in full if you consult a specialist who charges the Premier Rate. We pay up to. We cover these expenses up to. We pay the first R1 000 of your hospital account from your day-to-day benefits. We pay the balance of the hospital account and your related accounts from your Hospital Benefit. As part of an approved hospital admission: no overall limit. If admitted for conservative back or neck treatment: we pay the first R1 800 of the scan code from your day-to-day benefits. We pay the balance in full up to the Scheme Rate.. There is an overall limit of R for each person. This limit applies to in- and out-of-hospital dentistry and includes both hospital and related accounts. We pay the first R1 800 of your hospital account from your Medical Savings Account. We pay the balance of the hospital account from your Hospital Benefit. All related accounts are covered from your Medical Savings Account, subject to funds available. Cochlear implants and auditory brain implants and processors Internal nerve stimulators R for each person for each benefit R for each person

6 Hospital limits Hospital limits (continued) Hip and knee joint prostheses Prosthetic devices used in spinal surgery Mental health benefit Alcohol and drug rehabilitation Terminal care benefit Dialysis Unlimited and paid at Unlimited and paid at 21 days for each person 21 days for each person R for each person We cover these expenses in full as long as we have approved your treatment plan Chemotherapy and radiotherapy Childbirth We cover these expenses in full as long as we have approved your treatment plan Normal vaginal deliveries: a stay of three days and two nights in hospital Caesarean sections: a stay of four days and three nights in hospital 4 Cover for day-to-day medical expenses We pay for your day-to-day medical expenses, like GP visits, x-rays and blood tests, from your available Medical Savings Account. The Scheme pays claims for some day-to-day expenses to make the money in your Medical Savings Account last longer: Screening Benefit: the Screening Benefit covers a group of preventive screening tests blood glucose, blood pressure, cholesterol and body mass index for each person each year, up to a maximum of R95 at a Discovery Wellness Network provider. You must have this group of tests done at the same time. The Screening Benefit also covers a mammogram, a Pap smear, a prostate test (PSA) and HIV screening tests if referred by the appropriate medical professional. We cover the test from the Screening Benefit. The consultation fee is paid from your available Medical Savings Account. 1. We first pay costs from your Medical Savings Account We pay your day-to-day medical expenses from your available Medical Savings Account. While you pay contributions monthly, you have immediate access to the full Medical Savings Account for the year. The Medical Savings Account contribution is a fixed portion of your medical scheme contribution. The annual Medical Savings Account amounts: Income band Income band R0-R7 500 R Category Annual MSA Allocation Category Annual MSA Allocation Principal member R1 788 Principal member R1 980 Adult dependant R1 368 Adult dependant R1 476 Child dependant R444 Child dependant R516 Remember we pro-rate the Medical Savings Account if you join the Scheme after January. This means we calculate the amount based on the number of months left in the year when you join. You can check your Medical Savings Account balance on You need to pay for your day-to-day expenses if you run out of money in your Medical Savings Account. 2. Treatment in hospital that we cover from your day-to-day benefits We cover the following treatment you get in hospital from available funds in your Medical Savings Account: Casualty and emergency treatment, if you are not admitted to hospital Medicine to take home Certain external medical items.