How the scheme works

Transcription

1 Maxima Range Maxima Core RISK S Major Medical Benefit Chronic Disease Benefit RISK S 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. Day-to-Day Benefit PMB level of care applies at the Designated Pharmacy Provider, GP Network and Specialist Network only. FEDHEALTH membership means REAL Medical Aid, REAL Service and REAL Benefits. Introducing Maxima Core, a Hospital Plan. Maxima Core provides mid-20somethings with unlimited hospitalisation at all private hospitals, together with the peace of mind of a Chronic Disease Benefit that covers 25 chronic conditions at 100% of the Medicine Price List. It also offers freedom on important major medical expenses, like a significant amount for oncology treatment and various reduced co-payments. Treatment by Fedhealth Network specialists is covered at cost for in-hospital procedures. And includes essential value-adds, like the Screening Benefit, that offers a free annual flu vaccine for the whole family and 1 free Network GP visit per beneficiary per year. contributions Member Adult Dependant Child Dependant 534

2 [ 1 major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised major medical benefit (continued) Overall annual limit (OAL) Healthcare Professional Tariff (HPT) - Fedhealth Network GPs and Specialists - Non-Fedhealth Network GPs and Specialists ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHER- WISE SPECIFIED Covered at cost Covered at 100% of FR - Other Healthcare Professionals Covered at 200% of FR Prescribed Minimum Benefits (PMBs) in state hospitals Hospitalisation costs at negotiated tariff Co-payments See details on page 2 Alternatives to hospitalisation - Sub-acute facilities and physical rehabilitation facilities PMB level of care only Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Post-hospitalisation benefit Post-natal midwifery benefit Prostheses - Internal - External Psychiatric services Renal Dialysis (chronic) ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHER- WISE SPECIFIED R (See HPT above) at FR Up to 30 days after discharge at FR 4 consultations per pregnancy at FR Various sub-limits apply (see page 4) R9 970 at cost R (See HPT above) - Nursing services, private nurse practitioners & nursing agencies Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Emergency treatment in a casualty ward Female health benefit: contraceptives Immune deficiency related to HIV infection Oncology - Specialised medication at negotiated tariff with Europ Assistance at cost (See HPT above), subject to approval (See HPT above) Co-payment applies to surgical extraction of impacted wisdom teeth at FR (See HPT above) R at ICON. Subject to Standard Protocols (See HPT above) - Haemodialysis and peritoneal dialysis R at FR Specialised medication benefit (eg. biologicals) - oncology & non-oncology Specialised radiology at FR Take-out medicines 7 days medication per hospital event at MPL Terminal care benefit R at FR FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff MPL - Medicine Price List

3 [ 2 PROCEDURE co-payments CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPI- TAL/ FACILITY BILL ONLY Colonoscopy, Upper GI endoscopy R2 500 internal prosthesis benefit table This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth LIMIT PER FAMILY PER YEAR Detachable platinum coils R Open hiatus hernia surgery, Hysterectomy (unless for cancer), Inguinal hernia surgery, Varicose vein procedures R Spinal surgery, Joint replacements R6 720 Surgical extraction of impacted wisdom teeth R3 360 Arthroscopic procedures Ankle, Knee, Shoulder R2 500 Laparoscopic procedures Diagnostic, Nissen/ Toupey R2 500 All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered Cardiac stents Cardiac valves Cardiac pacemakers Aorta stent grafts R Intraocular lenses (per lens) R2 804 Carotid stents Peripheral arterial stent grafts Embolic protection devices Shoulder replacement Elbow replacement Hip replacement See combined benefit limit for all unlisted internal prosthesis* Knee replacement Bone lengthening devices Spinal plates and screws Other approved spinal implantable devices Combined benefit limit for all unlisted internal prosthesis *R21 308

4 screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health CRITERIA ALL LIMITS ARE PER BENEFICIARY 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 Women; ages 50 to 74 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme As per State EPI As per State EPI Cardiac Health Cholesterol screening (full lipogram) All lives; aged 20 and older 1 every 5 years General General practitioner consultation (in network only) Flu vaccination All lives All lives 1 every year 1 every year EPI - Expanded Programme on Immunisation chronic disease benefit Medication for approved chronic diseases is covered from this benefit Limit Conditions covered 25 Chronic Conditions below Formulary Restrictive formulary Designated Service Provider (DSP) Medi-Rite pharmacy HIV/ AIDS MEDICINE INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Limit Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%. 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. 25 CHRONIC CONDITIONS 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 [ 3 day-to-day benefit PMB level of care at Specialist Network, GP Network and Designated Pharmacy provider only

5 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. Benefits unique to Fedhealth: 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 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 - 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 The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk. 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. The dentist s account will need to be paid by the member. *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. Disclaimer: This document is a summary for information purposes only and does not supersede the rules of the Scheme. In the event of any discrepancy between this summary and the Rules, the Rules will prevail. A copy of the Rules is available on request.