FINAL BANKMED NAMIBIA SUMMARY OF BENEFITS Effective 01 JANUARY 2016 BANKMED CARE

Transcription

1 BANKMED NAMIBIA SUMMARY OF BENEFITS Effective 01 JANUARY 2016 BANKMED CARE OVERALL ANNUAL BENEFIT (OVERALL LIMIT) N$ PER BENEFICIARY N$ PER FAMILY CATEGORY A: HOSPITALISATION BENEFIT 1. Hospitalisation (Subject to Preauthorisation) COVER M M + 1 M + 2 M + 3 M % NAMAF TARIFF Pre-notification: tariff will be paid out. Without Pre-notification: 90% of tariff will be paid out Sub-limits are not Pro-rated Additional Hospital Benefit Cover: GP s and Specialists In-hospital services are paid up to a MAXIMUM of 225% of NAMAF Tariff PRIVATE HOSPITALISATION: N$ PER BENEFICIARY OVERALL LIMIT STATE HOSPITALISATION: UNLIMITED 1.1 Accommodation & Theatre Sub-limit Accommodation other than a recognised hospital/medical No benefit institution 1.3 Blood Transfusions Sub-limit Intensive and High Care - Maximum of 3 days then Sub-limit 1 motivation 1.5 Medicine, fixed tariff procedures, hospital apparatus and To Take Sub-limit 1 Out Medicine (7 days supply only) 1.6 Radiology & Pathology (in hospital) - Additional Hospital benefit Cover 1.7 Physiotherapy Physiotherapy ( in hospital) Physiotherapy (post rehabilitation) - Additional benefit once the patient is out of hospital No benefit 2. Specialised Radiology Procedures (in & out of hospital) - Referral from a medical specialist only (referral from GP acceptable in places where there is no medical specialist) 2.1 MRI & CT Scans Limited to N$ per Family 2.2 Nuclear Medicine 2.3 Radiation Oncology 3. General Practitioners and Specialists (in hospital services, procedures & operations) included 4. Internal Appliances & Materials Limited to N$ per Family 4.1 Artificial Eyes 4.2 Artificial Limb 4.3 Other Internal Appliances & Materials 5. Dialysis - BANKMED CARE

2 (Subject to Case Management ) 6. Oncology Active therapy (surgery, chemotherapy and radiotherapy) (Subject to Case Management and MHC Guidelines ) 7. Organ Transplant - Including immunosuppresant drugs and services rendered to the donor (Subject to Case Management and MHC Guidelines) 8. Hospice Facilities No Benefit 9. Private Nursing Limited to N$ per Family 10. Frail Care Limited to N$ per Family 11. Psychiatric Treatment hospitalisation - Referral from Psychiatrist only Limited to N$7 500 per Family (Referral by GP acceptable in places where there is no Psychiatrist) 12. Refractive Surgery (all-inclusive) No Benefit 13. Phakic Implants (lens Implant) (all-inclusive) No Benefit 14. Reconstructive Surgery (Medical necessity only) (all-inclusive) (Subject to pre-authorisation and strict No Benefit MHC Guidelines) 15. Dental Surgery Excluded 15.1 Dental Implants - Hospitalisation No benefit Maxillo Facial & Oral Surgery (Non-Elective Only) - Full Procedure Maternity 16.1 Confinement (Limited to 1 confinement per year for dep. Other than the spouse) Limited to N$ per Family (Benefit for Trauma only) Procedure Hospitalisation Sub-limit Ante-natal Consultation 16.3 Sonar Scans (excluding 3D) 16.4 Amniocentesis 16.5 Midwifery Service 17 Insertion Intrauterine Device w/ hormone (Mirena) (All-inclusive) (Subject to Prior approval) 18. Ambulance & Evacuation Services Limited to 12 consultations per Beneficiary (Pro-rated from date of joining) Limited to 2 scans per Beneficiary per pregnancy Limited to N$5 000 per beneficiary 18.1 Emergency Ambulance & Flights 18.2 Ambulance/Inter-hospital transfer 18.3 Other Conveyances Transport benefit for medical services available only in RSA 80% of - BANKMED CARE

3 19. International Medical Travel Insurance - Medical cover when travelling to foreign countries - For emergency cases only (not for elective surgery or procedure) 20. Specified Illness Conditions (Subject to pre-authorisation) 20.1 HIV/AIDS (As per National Guidelines for Antiretroviral Therapy) Medicine - Medicine Price List on generics First Full HIV Consultation / Assessment Consultation (after the first full HIV consultation / assessment) N$ per incident Limited to N$ per Beneficiary Sub-limit 20 N$355 N$ HIV Counselling VCT (Rapid HIV test, pre & post counselling) N$50 Once off benefit Sub-limit 20 Limited to 6 consultations per Beneficiary Sub-limit 20 Limited to N$1 000 per Beneficiary Sub-limit 20 Limited to 2 VCT s per Beneficiary at recognised VCT Centres Sub-limit Pathology Tests Sub-limit HIV Resistance Test 20.2 Prophylactic Treatment mother to child Sub-limit 20 Sub-limit Rape Cover Sub-limit Needle-stick Injuries Sub-limit Sexually Transmitted Diseases Sub-limit Drug & Alcohol Addiction Limited to N$1 000 per Family subject to report to HR Head Office - BANKMED CARE

4 CATEGORY B: DAY TO DAY BENEFITS COVER % NAMAF TARIFF Overall Sub-Benefit Limit Limited to N$9 000 per Beneficiary Limited N$ per Family Conditions: Sub-limits are pro-rated from date of joining, Except Optical Benefit OVERALL ANNUAL LIMIT M M + 1 M + 2 M + 3 M General Practitioners & Specialists N$3 550 N$4 750 N$5 250 N$5 500 N$ Consultations/Visits (out-ofhospital) Consultations Consultations Consultations 21.2 Procedures/Services (out-ofhospital) Sub-limit Materials and Disposable Items Sub-limit Radiology & Pathology Referral from Medical Practitioner Sub-limit 21 required Refer to Sub-limit Dentistry Limited to N$3 100 per Family 12 Consultations 12 Consultations Limited to N$1 100 per Beneficiary (excluding Orthodontics Benefit) 22.1 Basic Dentistry (Check ups, x-rays, preventative treatment, removal of teeth, simple filling) 22.2 Specialised / Advanced Dentistry (Root canal treatment, plastic dentures, periodontal treatment crown & bridge work & metal & soft bases dentures) Dental Implants (Consultation, Procedure & Implant Component) Sub-limit 22 Sub-limit 22 No Benefit Refer to Sub-limit Orthodontics No Benefit 23. Medicine & Injections 23.1 Acute Medicine 23.2 Chronic Medicine 23.3 Chronic Medicine (Pensioners) 23.4 Essential Vaccination/ Immunization (As per WHO Guidelines) Medicine Price List on generics 23.5 Self Medication 24. Primary Health Care Services 80% 80% Limited to N$9 000 per Family Limited to N$5 000 per Beneficiary Sub-limit 29 Limited to N$360 per Family Limited to N$60 / script / Beneficiary / Day 24.1 Consultations Sub-limit Medicine & Injections 80% Refer to Sub-limit 29 - BANKMED CARE

5 25. Auxiliary Services (Supplementary Services) Limited to N$3 480 per Family (20% ) Limited to N$1 400 per Beneficiary 25.1 Appliances (External) (Subject to MHC guidelines) 25.2 Biokinetics 25.3 Clinical Psychology / Psychological Counsellor 25.4 Physiotherapy 25.5 Chiropractor Consultation & Procedure Medicine 80% 25.6 Homeopathy/naturopathy/ Phytotherapy/Osteopathy Consultation & Procedure Medicine 80% 25.7 Audiology/Speech Therapy 25.8 Hearing Aid Acoustician 25.9 Podiatry/Chiropody Dietician Occupational Therapy Social Worker (Motivation required) Orthotist/Prosthetist Refer to Sub-limit Wheelchair Limited to N$2 170 per beneficiary every 4 years(2015/2018) - Inclusive of repair & maintenance 27. Hearing Aids Apparatus - Inclusive of repair & maintenance Limited to N$5 000 per Beneficiary every 2 years (2014/2015) 28. Optical Limited to N$3 000 per Family Limited to N$1 400 per Beneficiary every 2 years (including frames) 28.1 Eye Test Limited to one eye test per Beneficiary per annum Sub-limit Contact lenses/spectacle lenses Sub-limit Frame Sub-limit Benefit Booster Applicable if Medicine & Injections, Dentistry, GP s & Specialists, Primary Health Care and Auxiliary Services benefits are depleted. Limited to N$1 450 per Family Limited to N$725 per Beneficiary 29.1 Medicine & Injections (Acute & Chronic) 70% Sub-limit 29 - Excluding Self-Medication 29.2 Medicine & Injection (Chronic Pensioner) 90% Sub-limit Dentistry & Dental Implants (Excluding Orthodontic) 70% Sub-limit General Practitioners & Specialists (Consultations/Visits & Procedures/Services out-ofhospital) 80% Sub-limit Primary Health Care 80% Sub-limit Auxiliary Services 70% Sub-limit Health SmartCard No Additional Costs. Each Dependant will receive his/her own smartcard. Benefits can be verified at Service Providers 24/7. In case of Emergency, Member and Dependants can be identified without Health Smartcard. Next of Kin can be contacted immediately. - BANKMED CARE

6 OVERALL ANNUAL BENEFIT (OVERALL LIMIT) CATEGORY A: HOSPITALISATION BENEFIT BANKMED NAMIBIA SUMMARY OF BENEFITS Effective 01 JANUARY 2016 BANKMED ESSENCE N$ PER BENEFICIARY N$ PER FAMILY COVER M M + 1 M + 2 M + 3 M % NAMAF TARIFF Pre-notification: tariff will be paid out. Without Pre-notification: 90% of tariff will be paid out Sub-limits are not Pro-rated OVERALL LIMIT Additional Hospital Benefit Cover: GP s and Specialists In-hospital services are paid up to a MAXIMUM of 225% of NAMAF Tariff 1. Hospitalisation (Subject to Preauthorisation) 1.1 Accommodation & Theatre 1.2 Accommodation other than a recognised hospital/medical institution Limited to N$500 per day per Family (Maximum of 2 days) 1.3 Blood Transfusions 1.4 Intensive and High Care - Maximum of 3 days then motivation 1.5 Medicine, fixed tariff procedures, hospital apparatus and To Take Out Medicine (7 days supply only) 1.6 Radiology & Pathology (in hospital) - Additional Hospital benefit Cover 1.7 Physiotherapy Physiotherapy ( in hospital) Physiotherapy (post rehabilitation) - Additional benefit once the patient is out of hospital N$5 000 per family 2. Specialised Radiology Procedures (in & out of hospital) - Referral from a medical specialist only (referral from GP acceptable in places where there is no medical specialist) 2.1 MRI & CT Scans 2.2 Nuclear Medicine 2.3 Radiation Oncology 3. General Practitioners and Specialists (in- hospital services, procedures & operations) included 4. Internal Appliances & Materials 4.1 Artificial Eyes 4.2 Artificial Limb 4.3 Other Internal Appliances & Materials 5. Dialysis (Subject to Case Management and MHC Guidelines) ) 6. Oncology -Active therapy (surgery, chemotherapy and radiotherapy) Limited to N$ per Family Limited to N$ per Beneficiary every 4 years ( ) Limited to N$ per Beneficiary every 4 years ( ) - BANKMED ESSENCE

7 (Subject to Case Management and MHC Guidelines) 7. Organ Transplant - Including immunosuppresant drugs and services rendered to the donor (Subject to Case Management and MHC Guidelines)) 8. Hospice Facilities 9. Private Nursing Limited to N$ per Family 10. Frail Care Limited to N$ per Family 11. Psychiatric Treatment hospitalisation - Referral from Psychiatrist only (Referral by GP acceptable in places where there is no Psychiatrist) Limited to N$ per Family 12. Refractive Surgery (all-inclusive) (Subject to pre-authorisation & MHC N$ per eye per Beneficiary (once-off benefit) Guidelines) 13. Phakic Implants (lens Implant) (all-inclusive) N$ per Beneficiary (once-off benefit) 14. Reconstructive Surgery (Medical necessity only) (Subject to pre-authorisation and strict MHC Guidelines) 14.1 Consultation and Procedure Limited to N$ per Family 14.2 Hospitalisation 15. Dental Surgery Excluded Dental Implants Hospitalisation 15.2 Maxillo Facial & Oral Surgery (Elective & Non-Elective) - All-inclusive Maternity 16.1 Confinement (all-inclusive) (Limited to 1 confinement per year for dep. other than the spouse) 16.2 Ante-natal Consultation 16.3 Sonar Scans (excluding 3D) 16.4 Amniocentesis 16.5 Midwifery Service 17. Insertion of Intrauterine Device w/ hormone (Mirena) (All-inclusive) (Subject to Prior approval) 18. Ambulance & Evacuation Services Limited to N$8 000 per Beneficiary Limited to N$ per Family Limited to N$ per Family Limited to 12 consultations per Beneficiary (Pro-rated from date of joining) Limited to 2 scans per Beneficiary per pregnancy Limited to N$5 000 per beneficiary 18.1 Emergency Ambulance & Flights 18.2 Ambulance/Inter-hospital transfer 18.3 Other Conveyances Transport benefit for medical services available only in RSA 80% of - BANKMED ESSENCE

8 19. International Medical Travel Insurance - Medical cover when travelling to foreign countries - For emergency cases only (not for elective surgery or procedure) N$ per incident CATEGORY B: DAY TO DAY BENEFITS COVER Sub-limits are pro-rated from date of joining, except Optical Benefit. OVERALL LIMIT % NAMAF TARIFF M M + 1 M + 2 M + 3 M General Practitioners & Specialists N$9 250 N$ N$ N$ N$ Consultations/Visits (out-ofhospital) Sub-limit Procedures/Services (out-ofhospital) Sub-limit Materials and Disposable Items Sub-limit Radiology & Pathology (Referral from Medical Practitioner) Sub-limit 20 Refer to Sub-limit Dentistry N$8 400 N$9 500 N$10 00 N$ N$ Limited to N$8 400 per Beneficiary (excluding Orthodontics benefit) 21.1 Basic Dentistry Sub-limit Specialised / Advanced Dentistry Sub-limit Dental Implants Consultation & Procedure (in-hospital) Consultation & Procedure (in-practice) Implant Component Limited to N$ per Family 150% Limited to N$ per family Limited to N$6 750 per Beneficiary Limited to N$ per Family Refer to Sub-limit Orthodontics Limited to N$ per Beneficiary (once-off benefit) 22. Medicine & Injections 22.1 Acute Medicine 22.2 Chronic Medicine 22.3 Chronic Medicine (Pensioners) 22.4 Essential Vaccination/ Immunization (As per WHO Guidelines) Medicine Price List on generics 22.5 Self Medication 23. Specified Illness Conditions (Subject to pre-authorisation) 23.1 HIV/AIDS (As per National Guidelines for Antiretroviral Therapy) 80% 80% N$ N$ N$ N$ N$ N$6 400 N$9 000 N$ N$ N$ Limited to N$6 400 per Beneficiary N$ N$ N$ N$ N$ Limited to N$ per Beneficiary Sub-limit 22 Refer to Sub-limit 30 N$1 440 N$1 560 N$1 680 N$1 800 N$1 920 Limited to N$180 per script per beneficiary per day Sub-limit 22 Limited to N$ per Beneficiary - BANKMED ESSENCE

9 Medicine Medicine Price List on generics First Full HIV Consultation / Assessment Consultation (after the first full HIV consultation / assessment) N$355 N$290 Once off benefit Limited to 6 consultations per Beneficiary HIV Counselling Limited to N$1200 per Beneficiary VCT (Rapid HIV test, pre & Limited to 2 VCT s per Beneficiary at recognised VCT Centres N$50 post counselling) Pathology Tests HIV Resistance Test (Subject pre-authorisation) 23.2 Prophylactic Treatment mother to child 23.3 Rape Cover 23.4 Needle-stick Injuries 23.5 Sexually Transmitted Diseases 23.6 Drug & Alcohol Addiction Limited to N$3 600 per Family subject to report to HR Head Office 24. Primary Health Care Services 24.1 Consultations Sub-limit Medicine & Injections 80% Sub-limit 22.1 Refer to Sub-limit Auxiliary Services (Supplementary Services) N$9 500 N$ N$ N$ N$ Biokinetics 25.2 Clinical Psychology / Psychological Counsellor 25.3 Physiotherapy 25.4 Chiropractor Consultation & Procedure Limited to N$4 500 per Beneficiary Limited to N$4 500 per Beneficiary Limited to N$4 500 per Beneficiary Medicine 80% Sub-limit Homeopathy/Naturopathy/ Phytotherapy/Osteopathy Consultation & Procedure Medicine 80% Sub-limit Audiology/Speech Therapy 25.7 Hearing Aid Acoustician 25.8 Podiatry/Chiropody 25.9 Dietician Occupational Therapy Social Worker Limited to N$4 500 per Beneficiary (Motivation required) Orthotist/Prosthetist Refer to Sub-limit Wheelchair Limited to N$ per Beneficiary every 4 years (2015/2018) - Inclusive of repair & maintenance 27. Appliances (External) 80% Limited to N$4 000 per family (Subject to MHC guidelines) 28. Hearing Aids Apparatus - Inclusive of repair & maintenance 29. Optical Limited to N$ per Family every 2 years (2014/2015) N$4 000 N$7 000 N$7 400 N$7 500 N$7 600 N$4 000 per Beneficiary limited to every 2 years (including frames) 29.1 Eye Test Limited to one eye test per Beneficiary per annum Sub-limit Contact lenses/spectacle lenses Sub-limit 29 - BANKMED ESSENCE

10 29.3 Frame 30. Benefit Booster Applicable if Medicine & Injections, Dentistry, GP s & Specialists, Primary Health Care and Auxiliary Services benefits are depleted 30.1 Medicine & Injections (Acute & Chronic) - Excluding Self-Medication 30.2 Medicine & Injections (Chronic Pensioner) 30.3 Dentistry & Dental Implants (Excluding Orthodontic) 30.4 General Practitioners & Specialists (Consultations/Visits & Procedures/Services out-ofhospital) Limited to N$1 100 per Beneficiary Sub-limit 29 Limited to N$2 750 per Beneficiary Limited to N$5 050 per Family 70% Sub-limit 30 90% Sub-limit 30 70% Sub-limit 30 80% Sub-limit Primary Health Care 80% Sub-limit Auxiliary Services 70% Sub-limit Health SmartCard No Additional Costs. Each Dependant will receive his/her own smartcard. Benefits can be verified at Service Providers 24/7. In case of Emergency, Member and Dependants can be identified without Health Smartcard. Next of Kin can be contacted immediately. - BANKMED ESSENCE