MEMBER GUIDE. Feel confident that someone is always on your side

Transcription

1 2014 MEMBER GUIDE Feel confident that someone is always on your side

2 READY TO LIVE THE LIFE YOU DESERVE? Everyone wants to lead their best life. We want tomorrow to be better than yesterday and we want to know that when things get tough, we have all the support we need; whether it s from family, friends or even a scheme like Bonitas. That s why at Bonitas, we re not just in the business of healthcare. Yes, we offer quality, affordable healthcare plans and benefits and yes, when you have a health issue, we re there for you, but that s just the beginning. Our business is about supporting your life. We start by making it simple to get the help you need, when you need it. We want tomorrow to be better than yesterday and we want to know that when things get tough, we have all the support we need. This means that we have a wide network of top doctors, hospitals and pharmacies, waiting to attend to you. We also have a range of products that are simple to understand so that you know exactly what you are insured for. They re also simple to use, with up to 90% of your bills being paid directly by us so you don t have to worry about paying out of your pocket. Most of all, our products are affordable and flexible, adapting to all needs and budgets. At Bonitas, we believe everyone has the right to live their perfect life, and you can only do that when you know you have the support of people who care.

3 ABOUT BONITAS Bonitas Medical Fund has a proud 32-year heritage of providing value-for-money healthcare benefits to all South Africans. The second largest open medical scheme in South Africa, Bonitas provides healthcare products and services of exceptional quality to a growing membership base of more than members. Our range of transparent and simple-to-understand products are designed to cover the full spectrum of members needs, from CEO to the entry-level worker, which is why over 50% of our members are employees of large corporate organisations including BHP Billiton, Eskom, Vodacom, Coca Cola, Post Office and Telkom. Bonitas is serious about its members needs. Bonitas Charter As a non-profit organisation that exists solely for the benefit of our members, Bonitas has been entrusted with the responsibility for providing for our members' healthcare needs. This is a responsibility Bonitas takes seriously and we therefore undertake to: Always act in the best interests of members and dependants Provide healthcare benefits of exceptional quality and substance Ensure that value-for-money is always a top priority Design relevant benefit options that are easy to understand Deliver outstanding service Adhere to the highest standards of financial management and corporate governance. Financial soundness R3.3 billion reserves AA- Global Credit Rating 33.3% solvency ratio Administration cost only 5.92% of gross contribution income Value propositions Seven flexible options to choose from Free cover for the fourth and subsequent child dependants Child rates for student dependants up to the age of 24 with proof of enrollment at an institution Comprehensive maternity benefits per event Dedicated on site consultants Clinically approved HCT programmes Unique set of dental benefits (DENIS) Optical Benefits (PPN) Customised wellness days CDE benefits (Centre for Diabetes and Endocrinology) Member Guide 2014 Page 03

4 FUND HIGHLIGHTS OF THE FUND MEMBERSHIP RULES IMPORTANT INFORMATION WAITING PERIODS WHEN CAN I EXPECT PAYMENT? HIGHLIGHTS OF THE FUND Product offering We have has seven flexible options tailor-made to address the challenging healthcare needs of South Africans. New Generation Options The three New Generation Options are BonComprehensive, BonSave and BonClassic. These options enhance the competitiveness of Bonitas in the corporate market. Traditional Options There are three Traditional Options, namely the Standard Option, the Primary Option and BonCap. Additional value-added services We believe that a preventative approach and adequate cover for essential services to healthcare is vitally important to improve the quality of life of our members. Bonitas offers its members a range of additional value-added services: 1 flu vaccine per year for all beneficiaries 1 HIV test per year for all beneficiaries Access to a HIV management programme Infant paediatric benefit Childhood illness benefit Page 04 Member Guide 2014

5 MEMBERSHIP RULES HOW DO I JOIN? Joining through your employer Complete an application form for membership and hand it to the payroll department who will forward it to Bonitas new business department. Remember to register your dependants on the application form. Your company's HR and payroll department will handle all changes that affect your membership. This will ensure that the information on your salary slip is correct. Joining as a direct paying member Complete an application form for membership, which is available on the Bonitas website or from your broker, and forward to Bonitas new business department. Direct paying members contributions are to be paid through the following methods: Cash deposits Debit orders Contributions are due by the 7th of the month. Debit orders are collected on the first working day of the month. If Bonitas receives your application form between the 1st and the 15th of the month, your membership will be effective on the 1st of the following month. If your application form is received after the 15th of the month, your membership will be effective 2 months thereafter, e.g. if the administrator receives your application form on 16 January, your membership will be effective from 1 March. Banking details If your banking details change, kindly advise Bonitas and your payroll department immediately. You will also be required to submit your latest bank statement and a copy of your ID to validate the change. Changes to your personal details: It is important that the administrator has your latest details so that claims can be handled efficiently. Bonitas should be advised of the following within 30 days: Changes to your marital status. Changes to one of your dependant's status. Birth or legal adoption of a child. Any dependant who is no longer entitled to membership. Changes to your contact details and / or banking details. Who can be registered as a dependant? Your spouse and dependant children up to age 21. Student dependants aged 21 to 24 subject to proof of study at a recognised institution of learning (registration documents). Your partner and other members of your immediate family who are financially dependent on you for family care and support may also be registered if specific criteria are met. Pro-ration of benefits If you join Bonitas during the year, benefits will automatically be pro-rated accordingly. This means that you will only have access to a percentage of your benefits based on the month you join us from until the next benefit year begins. Child dependants You only pay contributions for the first three child dependants. The fourth and subsequent child dependants are free. Can I belong to more than one scheme? No, as per Section 29 of the Medical Schemes Act, dual membership is not allowed for principal members and dependants. Members need to ensure that they terminate their previous medical aid before joining another medical aid. Proof of membership When joining Bonitas, a membership card will be issued to you. The card will reflect your membership number, your name, the names of your registered dependants as well as the date from which you are entitled to benefits. When you receive the card, please check that all the details on the card are correct. If not, please advise your payroll department, healthcare broker or the administrator. If you do not receive your membership card within two weeks, please call us on Do not lend your card to anyone. Use of the card by anyone other than the principal member and registered dependants is illegal and will result in criminal prosecution and termination of membership. Member Guide 2014 Page 05

6 IMPORTANT INFORMATION Fraudulent use of membership cards results in increased costs that affect all members. Phone the toll-free Fraud Hotline on and report cases of fraud or abuse of the Fund. Persal members Please note that Bonitas Medical Fund will strictly adhere to the payment run dates given by Persal. Join dates If you are not currently on another medical scheme, your join date will be loaded as a future date (approximately 2 months later). The same guidelines apply if you are currently on another Scheme as Persal contributions are paid in advance and not in arrears. What is required for the processing of my application? A copy of an ID document for the principal member and all beneficiaries, or passport, marriage certificate, birth certificate and legal adoption or foster care, court order documents. Copy of previous membership certificate. An affidavit is required if the accountholder's details differ from the principal member. Who qualifies as an adult dependant? Your spouse and any other approved dependant aged 21 years or older. Who qualifies as a child dependant? A dependant under 21 years of age. Child dependant rates will apply up to and including the last day of the calendar month that the dependant turns 24 years of age, subject to valid proof of registration at a recognised institution of learning. Continuation of membership Continuation of membership refers to dependants of deceased members wanting to continue as main members on the Fund i.e. widows, widowers, orphans. Documents required A letter from the dependant advising the Fund of their intention to remain on the Fund as the principal member A copy of the Identity Document for the continuation of member and dependants Bank details for the collection of contribution together with a copy of the bank statement or cancelled cheque Updated contact details i.e. postal, physical address, telephone, cellphone numbers and address When does my membership end? Your membership is terminated when you no longer pay your contributions. You may also resign from the Fund after giving one calendar month written notice. For more information contact us on Contribution query [email protected] Page 06 Member Guide 2014

7 WAITING PERIODS Waiting periods for new applicants According to the Medical Schemes Act, Bonitas may impose a general waiting period of up to 3 months and a condition-specific waiting period of up to 12 months on you or your dependants if, you or your dependants were not beneficiaries of a medical scheme for a period of at least 90 days before you applied to join Bonitas Medical Fund. The condition specific waiting period will apply to medical conditions that existed before you joined the Fund. Waiting periods will also apply if you have never been a member of a medical scheme. Prescribed Minimum Benefits (PMBs) will not be available to you and your dependants during these waiting periods. The Fund may apply late joiner penalty to an applicant or any adult dependant who qualifies for late joiner penalty as per the Fund rules. When will waiting periods not apply? No waiting periods will apply to registered child dependants born during the period of membership; as long as the child is registered within 30 days from date of birth. No waiting period will apply to the main member if you are forced to transfer membership due to a change of employment or life changing event. If your employer moves to another medical scheme and the change is made within a 90-day period, no waiting period will apply. Any outstanding portion of a waiting period imposed by a former scheme will, however, apply. You will be entitled to PMBs except when there are outstanding portions of waiting periods. The Fund s rules specify that the relationship between Bonitas and its members must be one of the utmost good faith at all times. It is the member's duty to disclose all and any information relating to the member's claim that might have a bearing on decisions by the Fund. How to submit your claims Submitting claims correctly will ensure that your claim is paid quickly and efficiently. Here are some tips on what is required: Make sure that your membership number is clearly indicated on both the account and the receipt. Mail or your original account and receipt to Bonitas as soon as you can. Claims not received within four months from date of treatment are regarded as stale and will not be paid. If you have already paid the account and have attached the receipt, clearly mark the account paid by member. Please do not submit accounts that are marked for your information only, or accounts that only show a balance brought forward. These accounts are for your records only and should be used to check payments reflected on your statements. The Medical Schemes Act requires that healthcare providers give full details on all accounts. Please check that your account shows the following: Your name and initials Your medical aid number The treatment date Name of patient (as shown on your membership card Nicknames are not acceptable) The amount charged, tariff and ICD-10 code Check that prescriptions for medicine show all your details Also check that the correct amount of medicine dispensed is shown on the claim. If the pharmacy omits any of these details, Bonitas will not be able to process your claim. Please post all claims to: Bonitas Claims Department PO Box 74 Vereeniging claims to: [email protected] Member Guide 2014 Page 07

8 WHEN CAN I EXPECT PAYMENT? Bonitas pays claims on a weekly basis. Claims refunds are only paid into a bank account. Claims are no longer refunded via cheque. You should provide Bonitas with your bank account details for electronic refunds. Please contact us on to update or provide all the necessary details. How will I know what was paid? A statement will be sent to you, either by post or , at the end of the month. It will show the following information: The amount that may be claimed for tax on claims paid during the current and previous tax year Member/beneficiary status Benefit summary Member and provider portions for claims processed Your claim refund (electronic bank transfer) Savings account details Web-based query facility If you have internet access you will be able to log into a secure area to view your statements, claims history, monthly contribution, personal information and much more. You will also be able to view your benefits and update certain personal details. Visit and follow the steps to register. Claims against the Road Accident Fund (RAF) and Injured on Duty (IOD) If you are involved in a car accident and have a possible claim against the Road Accident Fund, remember that Bonitas offers the services of attorneys to assist you with legal advice. Please contact the call centre for further details. Note: If you are unsure of the benefits offered by Bonitas, or if you sustain injuries as a result of an accident, an assault or an injury on duty, please contact us on to discuss what you should do. Bonitas rates vs Private rates We will pay all claims at the Bonitas Rate. This will vary depending on the option chosen from 100% up to 300%. Some service providers might charge you private rates for services rendered, therefore you may be liable for any difference. Please verify which rate your service provider is charging before the service is rendered. Page 08 Member Guide 2014

9 ICD-10 CODES MEDICAL SAVINGS ACCOUNT EMERGENCY MEDICAL SERVICES ICD-10 CODES All healthcare providers in South Africa are required by law to include diagnostic information in the form of an ICD-10 code on all claims or accounts. These codes must be provided in addition to treatment codes, such as for consultations, surgery and so on. This requirement applies to all claims - whether the healthcare provider submits the claim directly to your medical scheme, or you pay at the time of service and then claim your benefits from your medical scheme. Any claim or account that does not have accurate and complete ICD-10 code/s may be rejected, resulting in non-payment by your medical scheme. Healthcare providers are familiar with the need to include an ICD-10 code on medical scheme claims. What is ICD-10? ICD-10 stands for International Classification of Diseases and related health problems. It is a set of codes which has been developed by the World Health Organisation (WHO) that translates the written description of medical and health information into codes in a standardised format. This set of codes forms part of an international standard, with which South Africa is now required to comply in accordance with the Regulations to the Medical Schemes Act. Why does Bonitas need an ICD-10 code on claims? ICD-10 codes provide the following benefits: Reliable statistics mean that Bonitas can plan correct management of your medical services and benefits Faster payment of your claims Reliable statistical data of members' prevalent illnesses, leads to improved research and treatment plans Statistical data allows South Africa to compare its health information with that of other countries and base medical benefit design on South African patterns of disease, rather than assuming these are the same as those of other countries Correct coding of Prescribed Minimum Benefit (PMB) conditions ensures payment from the appropriate benefit pool Ensuring confidentiality of your condition/illness, since that information is now supplied to Bonitas in coded form. The diagnosis information provided through ICD-10 codes is a form that increases confidentiality. As with all your other personal details and clinical information contained in your medical accounts, these ICD-10 codes will be handled in a confidential manner, ensuring the continued privacy and security of your information. Member Guide 2014 Page 09

10 MEDICAL SAVINGS ACCOUNT Bonitas Medical Fund provides a Personal Medical Savings Account (PMSA) on the BonSave, BonComprehensive and BonClassic options. This savings account will pay your day to day medical expenses such as GP consultations and acute medicine. The sum of your PMSA contributions is credited in advance on an annual basis. If you join the Fund during the year, the PMSA will be pro-rated. Any unused balance in your savings account at the end of each year is carried over into the new year. Threshold benefit (BonComprehensive only) The number and type of dependants of the principal member determine the annual threshold level. The threshold is a safetynet which provides cover for your day-to-day expenses once your PMSA and claims have been calculated to the predetermined threshold level. In order to access threshold cover you will need to have incurred expenses which exhausted your annual PMSA and the calculated self-payment gap. Certain types of claims will accumulate to the threshold level. Other types which can be paid from the savings facility will not accumulate, for example: the difference between the Bonitas Rate and Private Rate; other copayments and claims paid in excess of the benefit limit will not accumulate. You are now paying out of your own pocket. You must submit all claims, even if your PMSA has been exhausted. All claims are assessed to determine whether they will accumulate to your threshold level. Claims accumulate at 100% of the Bonitas Rate for eligible day to day medical expenses. Once in the threshold, a 25% co-payment is payable by the member. There is an annual sub-limit for optometry Once a sub-limit is reached, no further benefits in respect of that specific category are payable from threshold cover for the remainder of the benefit year. 25% co-payment applies to day to day medical expenses in threshold. The annual threshold level will be adjusted or pro-rated during a benefit year should a member join or dependants be added or terminated during the year. savings therefore a principal member will have a self payment gap of R976. Thereafter you are covered for extra benefits subject to sub-limits and 25% co-payment. In summary: 1. Optometry benefits have a sub-limit. The sub-limit is the maximum benefit allocated for the benefit year. 2. All day to day expenses (including dentistry) are paid from savings at 100% of the cost of the claim. Claims accumulate to threshold at 100% of the Bonitas rate. Please note: Payments from major medical cover do not accumulate to the threshold level. What happens if you leave Bonitas? If you leave Bonitas, and join a scheme with a savings account, the full amount due from your savings and bonus accounts will be transferred to the savings account of your new scheme. This will take place after a waiting period of five months. However, if you do not join another medical scheme, or if the medical scheme you are joining does not have a savings account, the full balance in your savings account will be paid in both cases to you. Note: This refund to you is taxable and must be declared in your annual income tax return. Should you leave Bonitas during the year, the savings amount due to you will be prorated according to the number of months you were a member of Bonitas. If claims at that stage exceed the prorated value available, the shortfall will be recovered from you. The shortfall will firstly be recovered from any balance available in your bonus account, if the balance available in your bonus account is insufficient, we will recover the amount from you. The diagram below illustrates how the threshold/self payment gap calculation works. Note that the example below is based on a principal member only. Annual threshold limit is R Member savings are 15% (R502 X12) = R Self payment gap = Annual threshold - Annual Page 10 Member Guide 2014

11 EMERGENCY MEDICAL SERVICES ER24 is the designated service provider for all emergency medical services for Bonitas members and their registered dependants. ER24 benefits: Emergency medical response via road or air to the scene of the medical emergency Transfer to the closest appropriate medical facility via road or air (whichever is appropriate) Inter-hospital transfers subject to authorisation by ER24 in accordance with Scheme rules Medical information and assistance hotline Trauma counselling and referral to appropriate healthcare professionals as required Member/dependant validation What to do in the case of a medical emergency: Call Provide your name and the telephone number you are calling from (including the area code) Provide a brief description of the incident and the severity thereof Provide the address/location (road name, number and nearest crossroad) Do not hang up until ER24 has all the details Important: ER24 encourages you to ensure that your specially designed Bonitas - ER24 stickers are attached to your vehicle(s) as described in the letter sent with the stickers. In the case of a member involuntarily using another service provider, please ensure that ER24 is informed thereof and that the account is submitted to [email protected] no later than 30 days after the date of service. ER24 medical information and assistance hotline: Trained medical personnel provide general medical information and advice regarding: Medical attention required General medication advice in accordance with best practice guidelines Trauma counselling - telephonic advice and referral to specialised services as required, e.g.: Hijacking, armed robbery, assault, rape Domestic violence, child abuse, kidnapping Bereavement, suicide, drug abuse, poisoning HIV counselling and advice Call at any time Member Guide 2014 Page 11

12 PHARMACY DIRECT - DESIGNATED SERVICE PROVIDER (DSP) Pharmacy Direct is a courier service pharmacy that specialises in the reliable delivery of chronic medication, as well as Antiretroviral Therapy, to patients nationally. Medication is delivered to your home, place of work or to the nearest Post Office, depending on your choice. A large number of our patients are based in rural areas where there are no other pharmaceutical services available. Pharmacy Direct has the capability to deliver medication to members and dependants residing at different addresses. Patients are advised by SMS, telephone or of delivery. Business hours: Monday to Friday: 7:30am 5:00pm Delivery of medication: First time delivery for urgent/life-threatening medication 48 to 72 hours First time delivery of other chronic medication 5 to 7 working days Repeat delivery: Medication is automatically dispensed on a 28-day cycle. Pharmacy Direct uses an advanced scheduling and planning system to deliver medication to patients on a regular monthly basis. Patients do not have to re-order medication each month. How do I join Pharmacy Direct? STEP 1: Complete all relevant sections on the Pharmacy Direct application form (available on the website) or alternatively phone the Pharmacy Direct call centre on to register an online application. STEP 2: Please fax a copy of the repeatable original prescription, for all the medication that will be needed (contact your doctor should you not have this with you), to Pharmacy Direct at fax number /1/2/3. STEP 3: Members using chronic medication should apply to Chronic Medicine Management for authorisation. This will ensure that your Page 12 Member Guide 2014

13 chronic medication will come from the Chronic Medicine benefit. STEP 4: An electronic copy of all documentation is acceptable. However, you are required to send your original prescription for schedule 6 medication to Pharmacy Direct. An electronic copy only will not be in compliance with legislation. Mail to: Pharmacy Direct, P O Box 7344, Centurion, 0046 Please note that it is the member s responsibility to cancel the current arrangement that exists for his/ her chronic medication. STEP 5: Please note that Pharmacy Direct can only dispense medication on receipt of a prescription from the doctor and it is the member s responsibility to obtain the script and forward this to Pharmacy Direct and to Chronic Medicine Management. ER24 is the designated service provider for all emergency medical services for Bonitas members and their registered dependants. Renewal of prescription Since January 2004, legislation has stipulated that prescriptions are only valid for a period of six months and that pharmacies may not dispense without a valid prescription. Pharmacy Direct therefore has to obtain a new prescription from members every six months to ensure compliance. Members can check the number of repeats available on the copy of the script sent with the medication, as well as on the label appearing on the medication. A renewal script will be required every 6 months. In the event that the renewal script is not received medication will not be delivered. Pharmacy Direct information: Practice number: Postal address: PO Box 7344, Centurion, 0046 Street address: 23 Kwartsiet Crescent Zwartkop Extension 15 Centurion Fax: /1/2/3 Queries: Aid for AIDS: Switchboard: (012) Website: [email protected] Member Guide 2014 Page 13

14 DENTAL BENEFITS (DENIS) BONITAS DENTAL BENEFIT INFORMATION General information DENIS, a fully accredited managed care organisation, manages your dental benefits on behalf of your medical scheme. There is a predefined benefit per procedure which is paid at the published Bonitas Dental Rate (see for the list of dental rates). Your dentist will also be able to provide information regarding your benefits, as DENIS supplies all dentists with a Chairside Guide, which illustrates the dental benefits. Benefits for dentistry are paid on a fee for service basis. This means that for every procedure done by a dentist, there is a fee that is charged. These fees may differ from dentist to dentist. Your fund pays a benefit for each procedure which may differ from the fee charged by your dentist. It is your right to negotiate this difference with your dentist. Please refer to the dental benefit table on pages 37 to 44 for the benefits per option and per treatment category. Familiarise yourself with the defined benefits as well as listed exclusions in the dental benefit table before visiting your dentist. By doing so, you will be fully aware of what your fund will pay towards your treatment. Conservative dentistry All conservative dental benefits, as set out in the dental benefit table, are covered at the Bonitas Dental Rate (BDT). How many check-ups do I have benefit for? Two general check-ups (consultations) are covered per beneficiary per calendar year. Benefit is subject to clinical protocols. Are x-rays covered? Benefit is subject to clinical protocols. Scheme exclusions: Electrognathographic recordings, pantographic recordings and other such electronic analyses. Oral hygiene instruction. Oral hygiene evaluation. Professionally applied adult fluoride. Dental bleaching. Page 14 Member Guide 2014

15 What benefit is available for oral hygiene procedures? There is benefit for two scale and polish treatments per beneficiary, per calendar year. Benefit is subject to clinical protocols. Benefit for fissure sealants is limited to individuals younger than 16 years of age. What benefit does Bonitas provide in respect of fillings? Benefit for fillings are granted once per tooth in a 3 year period. Benefit for re-treatment of a tooth is subject to clinical protocols. For extensive restorative treatment plans (multiple fillings) a treatment plan and x- rays may be requested. Scheme exclusions: Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis. Resin bonding for restorations that are charged as a separate procedure to the restoration. The polishing of restorations. Gold foil restorations. Ozone therapy. Extractions and root canal therapy? Benefit is subject to clinical protocols. On Primary and BonSave root canal treatment is limited to the shortened dental arch (i.e. excluding molars). Scheme exclusions: Direct and indirect pulp capping. Root canal therapy on primary (milk) teeth. What denture benefit is available on my option? Primary and BonSave Options: 1 set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period. Covered at the BDT, up to a limit of R1500 per beneficiary, per annum. Standard Option: 1 set of plastic dentures (an upper and lower) OR 1 partial metal frame denture (an upper OR lower) per beneficiary in a 4-year period. Covered at BDT up to a limit of R2000 per beneficiary per annum. BonClassic Option: 1 set of plastic dentures (an upper and lower) OR 1 plastic OR 1 partial metal denture per beneficiary in a 4-year period. Covered at BDT. BonComprehensive Option: 1 set of plastic dentures (an upper and lower) OR 2 partial metal frame dentures (an upper OR lower) per beneficiary in a 4-year period. Covered at BDT. Benefit is subject to clinical protocols. Benefit is not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered. Benefit is not available for the laboratory fee of mouth guards; the clinical fee will be covered. Scheme exclusions: Diagnostic dentures and associated laboratory costs. Snoring appliances and associated laboratory costs. High impact acrylic. The cost of gold, precious metal, semi-precious metal and platinum foil. Laboratory delivery fees. The metal base to full dentures and associated laboratory costs. Provisional dentures and associated laboratory costs. Partial metal frame dentures and associated laboratory costs on Primary and BonSave. Specialised dentistry All specialised dental benefits are covered at the Bonitas Dental Tariff (BDT). The following specialised dental benefits must be pre-authorised: Crown and bridge procedures Orthodontics Implants Hospitalisation Intravenous Conscious Sedation Periodontics What is pre-authorisation? Benefit pre-authorisation is the prior approval of any of the above listed specialised dental treatments. How do I get pre-authorisation? Call Have the following information ready when you phone Denis: Your Bonitas membership number Name of the practitioner and his/her telephone number and practice registration number A treatment plan including all relevant procedure codes and applicable tooth numbers, including diagnostic codes. Once authorisation has been obtained; cover for the treatment is subject to Fund rules, exclusions and benefit protocols. What happens if I fail to apply for preauthorisation? Procedures and treatment not pre-authorised will not attract a benefit with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been done. This does not apply to emergency hospital admission. Co-payments for specialised dentistry are levied on the Standard option. How do I get pre-authorisation for Crown and Bridge procedures? Call Send your treatment plan and clear clinical records together with the laboratory invoice to [email protected], Member Guide 2014 Page 15

16 Alternatively post to: Private Bag X 1 Century City 7446 Cape Town Further information may be requested in order to process your application. Assessment of a treatment plan and radiographic documentation is required for consideration of crown and bridge benefits. Should the benefit be approved, an authorisation letter will be sent to your treating dental practitioner. How many crowns do I have benefits for? Crowns are limited in quantity per family, regardless of the type of crown being placed. Primary Option: no benefit for crown and bridge procedures Standard and BonClassic Options: 1 crown per family per year, subject to pre-authorisation. BonComprehensive Option: 3 crowns per family per year. Benefits for crowns will be granted once per tooth in a 5 year period, subject to pre-authorisation. Benefit is subject to clinical protocols. Crown and bridge procedures that are NOT covered by the Fund: Crown and bridge procedures for cosmetic reasons and associated laboratory costs. Full mouth rehabilitations and associated laboratory costs. Provisional crowns and associated laboratory costs. Porcelain veneers and inlays and associated laboratory costs. Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs. The cost of gold, precious metal, semi precious metal and platinum foil. Laboratory delivery fees. How do I get pre-authorisation for Implant procedures? Call Send your treatment plan (including all three phases) to [email protected] or fax it to or post to: Private Bag X 1 Century City 7446 Cape Town Further information may be requested in order to process your application. Assessment of a treatment plan is required for consideration of implant benefits. Should the benefit be approved, an authorisation letter will be sent to your treating practitioner. Do I have benefit for dental implants? There is benefit for two implants per beneficiary, in a five year period on BonComprehensive only, which is subject to preauthorisation. Cost of implant components is limited to R1 750 per implant. Benefit is subject to clinical protocols. Scheme exclusions: Dolder bars and associated abutments on implants including the associated laboratory costs. Laboratory delivery fees. Note: Implantology and associated surgical procedures is a hospital exclusion. IV Conscious Sedation for dental implantology does not attract a benefit. How do I get pre-authorisation for orthodontic procedures? Call Send your treatment plan and clear clinical records to [email protected] or alternatively post to: Private Bag X 1 Century City 7446 Cape Town Further information may be requested in order to process your application. Assessment of a treatment plan and radiographic documentation is required for consideration of orthodontic benefits. Should the benefit be approved, an authorisation letter will be sent to your treating dental practitioner. Pre-authorisation is required for Removable appliance therapy, Functional appliance therapy, Partial fixed appliance therapy (Preliminary treatment) and Comprehensive fixed appliance therapy. What orthodontic benefit is available on my option? Orthodontic benefits are available on the Standard, BonClassic and BonComprehensive Options, subject to preauthorisation. A 20% co-payment of the Bonitas Dental Tariff (BDT) will apply to members on the Standard Option. Benefit is subject to clinical protocols. On pre-authorisation cases will be clinically assessed using orthodontic indices. Benefit on pre-authorisation will only be granted where function is impaired. Benefit will not be granted where orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered. Only one family member may commence orthodontic treatment in a calendar year. Benefit is limited to individuals younger than 18 years of age. A deposit is paid at the start of treatment and the balance is paid over the estimated treatment period. Orthodontic procedures that are NOT covered by Bonitas: Benefit will not be granted where Orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered. Orthodontic re-treatment and any related Laboratory costs. Orthognathic (jaw correction) surgery and any related Hospital and Laboratory costs. Invisible retainer material. Laboratory delivery fees. Page 16 Member Guide 2014

17 How do I apply for registration on the Periodontal Programme? This benefit is only available to those members on the Standard, BonClassic and BonComprehensive Options who are registered on the Periodontal Programme. To apply for the Periodontal Programme, submit your CPITN score (supplied to you by your dental practitioner), together with your Periodontal treatment plan to [email protected], or alternatively fax to Further clinical records may be requested to process your application. Benefit is subject to clinical protocols. Benefit is limited to conservative, non-surgical therapy only (root planing) and will only be applied to members who are registered on the Periodontal Programme. Scheme exclusions: Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemisection of a tooth. Periochip placement. Dental surgery: Benefit is subject to clinical protocols. Benefit for Temporo-mandibular joint (TMJ) therapy is limited to non-surgical intervention/treatments. Claims for oral pathology procedures (cysts, biopsies surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if supported by a laboratory report that confirms diagnosis. Surgical procedures that are NOT covered by Bonitas: Orthognathic (jaw correction) surgery Sinus lifts Bone augmentations Bone and tissue regeneration procedures The cost of bone regeneration material The auto-transplantation of teeth The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion. General anaesthetic and hospitalisation Hospitalisation benefit for dentistry is not automatically covered and is subject to pre-authorisation, where admission protocols apply. How to get authorisation before going to hospital Call us on , at least 48 hours prior to the planned procedure. Have the following information ready when you phone us: your Bonitas membership number the date of admission name of the practitioner and his/her telephone number and practice registration number the anaesthetist's practice number and contact details the name and telephone number of the hospital all relevant procedure codes and applicable tooth numbers, including diagnostic codes. in certain instances an x-ray, clinical report or additional information will be requested in order to process your preauthorisation. if the hospital admission is authorised, you will be supplied with an authorisation number, via your preferred method (fax or ). the hospital account will be paid according to the time allocated on the authorisation letter. Hospital accounts exceeding this time will be the member's liability. in the event of an emergency, after hours, let Denis know about your hospitalisation as soon as possible. Note: If you do not obtain authorisation before your hospital admission, the associated costs (hospital and anaesthetic accounts) will not be paid. What dental procedures are covered in hospital? Primary, BonSave, Standard, BonClassic and BonComprehensive Options: Hospitalisation benefits are available for the removal of impacted teeth. Benefit is subject to clinical protocols. In-hospital dental treatment for children: general anaesthetic benefits are available on the Primary, Standard, BonSave and BonComprehensive Options for children (0-5 years) who require extensive dental treatment (multiple extractions and fillings), subject to admission protocols. Multiple admissions are not covered. Requests for hospital admission that are NOT covered by Bonitas: Where the only reason for admission to hospital is dental fear and anxiety Multiple hospital admissions Where the only reason for the admission request is for a sterile facility; and The cost of dental materials for procedures performed under general anaesthesia. Note: The hospital and anaesthetist claims for the following procedures will NOT be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at the Bonitas Dental Tariff (BDT): Soft tissue impactions; Apicectomies; Dentectomies; Frenectomies; Implantology and associated surgical procedures Conservative dental Additional scheme exclusions treatment (fillings, extractions and root canal therapy) for adults; Professional oral hygiene procedures; and Surgical tooth exposures for orthodontic reasons. Member Guide 2014 Page 17

18 Nutritional and tobacco counseling. Caries susceptibility and microbiological tests. Pulp tests. Cost of Mineral Trioxide. Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments. Appointment not kept. Special report. Treatment plan completed. Dental Wellness Programme Dental testimony including dento-legal fees. Treatment plan completed (currently code 8120). Enamel micro-abrasion. Behaviour management. Intramuscular or subcutaneous injection. Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures. As a Bonitas member, you are automatically a member of the Dental Wellness Programme. You will receive various treatment related information leaflets and at your company's wellness says oral screenings, advice and dental products are provided. Visit for more information. Get your claims to Denis Post the original copies of your dental claims to: Private Bag X 1 Century City 7446 Cape Town You can your dental claims to [email protected]. When submitting a claim, please ensure the following details are clearly visible: Your membership number The dentist's details and practice registration number The correct dependant code (see your membership card) The treatment date The relevant procedure codes The applicable tooth numbers The relevant ICD-10 codes If you have already paid for the treatment, ensure that the appropriate receipt is attached. Denis contact details Call centre: Call centre fax: Enquiries: [email protected] Claims: [email protected] Hospital authorisations: [email protected] Orthodontic and implant authorisations: [email protected] Crown and bridge authorisations: [email protected] Periodontal authorisations: [email protected] will prevail. Dental Benefits (DENIS) Dental benefits are paid at the Bonitas Dental tariff (BDT). Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised**. Procedures and treatment not pre-authorised will not attract a benefit, with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been done. This does not apply to emergency hospital admission. Co-payments for Specialised Dentistry are levied on the Standard option. Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme exclusions apply to dental benefits. In the event of a dispute, the registered rules of the scheme prevail. BonComprehensive Option* The dental benefits of the BonComprehensive Option will be paid from the member's available savings and/or threshold limit as from 1 January The dental benefits as published below will apply, subject to Denis managed care protocols and managed care interventions which include pre-authorisation where necessary. Pre-authorisation is required for crowns, orthodontics, implants, periodontics, hospital and IV conscious sedation. A 25% copayment in threshold applies to all conservative and specialised dental procedures and treatment. Co-payments are not applicable to maxillo-facial surgery and hospitalisation. Please note that Medscheme will be responsible for the payment of all dental claims on the BonComprehensive Option. Additional scheme exclusions: Electrognathographic recordings, pantographic recordings and other such electronic analyses Nutritional and tobacco counselling Caries susceptibility and microbiological tests Fissure sealants on patients 16 years and older Pulp tests Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Appointment not kept Special report Dental testimony including dento-legal fees Treatment plan completed (currently code 8120) Enamel micro-abrasion Behaviour management Intramuscular or subcutaneous injection Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures Stale claims Claims that are not received within 4 months of date of treatment are, in terms of the Medical Schemes Act, regarded as stale and will not be eligible for benefit. In the event of a dispute regarding the benefit information illustrated above, the Rules of the Fund Page 18 Member Guide 2014

19 OPTOMETRY NETWORK Standard and Primary Options and BonClassic Preferred Provider Optometrists are a network of over 2000 optometric practices spread throughout the country, offering medical aid members substantial savings on clear single vision, aquity bifocal and aquity multifocal quality spectacle lenses. The PPN optometry network has been able to systematically reduce the cost of spectacle lenses over the last five years. As a result, you are able to stretch the buying power of your benefit by as much as 140%. Limited optical benefits are now more than adequate to cover your needs without increasing the cost of optical claims against the Fund. Making your optical benefit work for you Preferred Provider Negotiators (PPN) is the optical network of choice that Bonitas has contracted with to provide you with an insured optical benefit. PPN optometrists pride themselves in providing you with excellent service at all times, delivering the most cost effective eyecare without compromising professional standards or quality of products. PPN network optometrists charge tariffs that are up to 70% lower for certain spectacle lens prescriptions, thereby providing you with more products for your optical benefit. Frequently Asked Questions Can I visit a non-ppn optometrist? Yes you can, however, your medical aid s optical benefit is limited to the PPN tariff. Visiting a non-ppn optometrist will most likely result in you having to make a co-payment for your clear spectacle lenses. To avoid this, ensure that the optometrist you visit belongs to the PPN Network. Where can I find a PPN optometrist? The PPN network is the largest optical network in South Africa. To locate a PPN optometrist in your area, please contact our call centre on or visit our website - you can also contact our call centre for benefit enquiries, claim payments, and to report suspicious or fraudulent activity that you see or suspect for investigation. What does my optical benefit consist of? Your optical benefit depends on your Bonitas Option. PPN is contracted to manage the optical benefit for the Standard and Primary Options. The insured benefit (biennial) consists of a composite eye examination, a pair of clear standard spectacle lenses, or contact lenses, and a spectacle frame or spectacle lens enhancements as defined in the benefit brochure. PPN will make direct payment of the insured benefit to the contracted PPN optometrist. Call centre: Member Guide 2014 Page 19

20 MEDSCHEME MANAGED CARE What is Managed Care and why is it needed? Managed Care refers to various strategies and interventions that are applied by Bonitas to minimise our clinical and financial risk. This is important in controlling healthcare inflation and promoting the best clinical outcome for Bonitas members within given budgetary constraints. Tools used to achieve such goals include benefit design, health promotion, utilisation review, price intervention, as well as doctor and patient support programmes. Medicine management We make use of a number of different strategies to manage Bonitas members medicine usage. These include formularies, medicine price lists and medicine exclusion lists. Through these strategies, Bonitas is able to help its members to stretch their benefits further. Medicine Price List (MPL) MPL is a reference pricing system used in conjunction with formularies and pre-authorisation as a risk management tool to control medicine prices. The basic principle of any reference pricing system is that it does not restrict the choice of medicines, but instead uses a benchmark or reference price for generically similar products to limit the amount that will be paid. You are free to use any item which appears on the MPL. However, if the price of the item is more than the reference price, you will have to co-pay the difference at the point of sale. There is always at least one medicine available that will not incur a co-payment, so make sure you discuss your options with your doctor. It can help if your doctor can prescribe the active ingredient rather than trade name, or state on the script whether a generic substitution is permitted. Medicines requiring co-payments may vary from time to time due to price changes. Please check with your pharmacist /dispenser about co-payments that may apply to your medicine claims. MPL groups are created for: Items which are the generic equivalent, i.e. same ingredients, same strength or same formulation. Products which are generically similar and contain the same active ingredients, at the same effective strength, but the formulation may differ, e.g. tablets vs. capsules. The MPL list is reviewed monthly by a pricing committee and decisions are based on clinical expertise, market experience and business input. The products listed are from reputable companies to minimise the possibility of any particular product shortages, to ensure that you can access quality care with no co-payments. Page 20 Member Guide 2014

21 What is a generic medicine? A generic medicine has the same chemical ingredient, strength and formulation (i.e. tablet, syrup etc.) as the original brand name product. As with brand name products, the Medicines Control Council (MCC) checks the quality of every generic medicine before it is registered. Generic medicines are as effective and safe, but are usually cheaper than the original products as the cost of a brand name drug covers the money spent by the manufacturer in developing it. Research and development of generic medicine is mostly only available after the patent protection period for the original drug has expired. Although both original brand and generic medicines are accepted as equally reliable for individual patients, your condition may have to be monitored more carefully in the short-term when switching between different medicines, whether generic or brand name. Medicine Exclusion List (MEL) Bonitas makes use of a Medicine Exclusion List (MEL), which excludes medicines from being paid from the Acute Medicine Benefit for a number of reasons. These include: Medicines not proven to have relevant clinical value Medicines more expensive when compared to equally effective and safe cheaper alternatives Some expensive chronic medicines that require preauthorisation Some combination products, where it is more appropriate to use single ingredients products; and Newly registered products under review. Chronic Medicine Benefit Your Chronic Medicine Benefit is managed using a clinical preauthorisation process. The objective is to make sure you get optimal use of the Chronic Medicine Benefit by: Encouraging the appropriate use of medicines both clinically and based on cost; and Ensuring adherence to Fund rules and to treatment guidelines. The chronic pre-authorisation process is guided by a formulary, which refers to a set of drug-and disease-specific rules that guide reimbursement from the Chronic Medicine Benefit. Formularies Bonitas applies two medicine formularies to manage the high costs of medication associated with the chronic treatment of PMB diseases. A Formulary is a list of cost effective evidence-based medicines that the Fund will cover for the treatment of your chronic condition. These lists are compiled by CMM and are constantly reviewed. Reimbursement is subject to the CMM clinical guidelines and protocols, and the Medicine Price List (MPL). Your Scheme applies a Restrictive Formulary and a Comprehensive Formulary. The Restrictive Formulary, applicable to the basic or restrictive cover options, contains a list of medicines that provide adequate cover if a member is newly diagnosed, or if their condition is mild to moderate in terms of severity. Products included on this formulary will not attract a co-payment if authorised by CMM and obtained from the Designated Service Provider (DSP). The Comprehensive Formulary, applicable to the more generous options, provides access to a wider range of medicines for moderate to severe conditions Products included on this formulary will not attract a co-payment if authorised by CMM. If you choose to use a medicine that is out of formulary you may be liable to pay a co-payment, upfront at the point of dispensing. Your co-payment can also be further affected if the cost of your medicine is above that of the MPL. Please also note that if you are required to visit a DSP to obtain your medication and you choose not to, a possible further co-payment may apply for the use of a non-dsp, as determined by the Fund rules. Both formularies include alternative products that will not require a co-payment to be made, so if you do not wish to incur any copayments, discuss alternative therapies with your treating doctor and ensure that you obtain your medicine through a DSP. Drug utilisation review As part of the CMM process, interventions or non-authorisation may occur for the following reasons: Exclusion of non-evidence based medicine Evaluation of new drug products Therapeutic interchange Generic substitution Duration of authorisation limited pending review/ motivation/special investigations Authorisation only considered on motivation/special investigations/specialist prescription Drug-to-drug interaction Drug-disease interaction Disease authorisations: Your scheme has introduced a new way of approving chronic medicine to make management of changes easier for you, your pharmacist and your doctor. When you apply for chronic medicine, you are approved for treatment of your chronic condition and not a specific medicine only. However, you will have access to the full basket of medicine. This means that when you need to change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy with your new prescription without you having to contact us. It is important to note that not all conditions are managed this way and you may need to still call in to update us if you have a medicine that is not in your condition s basket or if you are diagnosed with a new condition. The quantity of each medicine in the basket is limited to the most commonly prescribed monthly dose. If you require higher quantities than those in the basket, you will have to contact us for authorisation. You do not need to update us with your new medicine if: your medicine is in the basket; or you change to another medicine in the basket; or you need a quantity or dosage of a medicine that is listed in the basket. Pre-approved medicine in the basket will still be subject to MPL and formulary co-payments. You can check for co-payments with your pharmacist or view the baskets, formularies and MPL lists on or login to Member Guide 2014 Page 21

22 How to apply for the Chronic Medicine Program? To have access to your chronic medicine benefit, you need to apply and be authorised for chronic medicine through the CMM Programme, subject to the CMM Clinical Guidelines and Protocols. The prescribed medicine that will be authorised is determined by your specific Fund option and medical scheme legislation and is subject to Fund rules, waiting periods and exclusions. Payment for the medicine is taken from your available Chronic Medicine Benefit. The registration process is then completed and the user may receive an immediate response for both of the above processes. To register for treatment of your chronic condition, you can follow the telephonic or online process shown below. You, your doctor, or pharmacist can complete the application. Make sure you have a copy of your current prescription with you during this phone call, although there is no need to send it in to us. Have the following information on hand: your membership number the date of birth of the person applying the ICD 10 code doctor s practice number medicine details To authorise certain medicine you may also need to supply: the clinical examination data, e.g. weight, height, BP readings, smoking status, allergy information test results, e.g. lipogram results, Hba1c, lung function tests motivation provided by your prescribing doctor Telephonic process: Call CMM on and follow the voice prompts. Once you select the appropriate option your call will be routed through to a consultant who will guide you through the process. Online process: Go to the Bonitas website at On the top right hand side of the web page login as a Member with your username and password. If you are a first time user you will need to register. Go to Clinical Information and click on Online Chronic Application. Follow the prompts on the system and once all information has been captured click on View Summary. You can print this screen for your records. Click on Submit and a reference number will be provided for follow up on the progress of the application. Important: Each beneficiary needs to have their own separate application but you can only complete this application form once. Once your application has been approved: Once registered and your application has been approved, you will receive a Medicine Access Card, listing the medicines to be paid from your Chronic Medicine benefit. If the medicine authorised differs from the medicine requested, a letter of explanation will be attached to your access card and a copy will be sent to the prescribing doctor. You will need a repeat script from your doctor for the medicines listed on the card. The access card is not a prescription and cannot be used to have medicines dispensed. Your doctor determines the number of repeats and will advise you how often he needs to see you to monitor your condition. Whenever you need to have your medicine dispensed, produce a valid doctor s prescription together with the access card. The duration of authorisation varies from medicine to medicine. Some medicines may be authorised ongoing; whilst others may only be authorised for a limited period. Important: To keep your authorisation active, you will need to submit a new script to your pharmacy every six months as per legislation. What if your medicine request has been declined? If any medicine request has been declined, e.g. requesting an out-of-formulary medicine, a letter of explanation will be sent to you and a copy will be sent to the prescribing doctor. Please ensure that the appropriate doctor provides the requested clinical information (where relevant). For online clinical decisions, your doctor or pharmacist should contact Healthcare Professional Managed Care on Your request will be reconsidered once all the relevant information has been received. Chronic Medicine Management contact details CMM member call centre: Healthcare Professional Managed Care call centre: [email protected] Where more clinical information is required, members of the clinical team will review the information supplied and correspond with you and your doctor, either telephonically or in writing, on the status of the medicine requested. Our consultants will confirm your consent after completion to ensure that you are aware of and agree with the application. You can follow up on the progress of your application by calling the CMM call centre. Page 22 Member Guide 2014

23 PRESCRIBED MINIMUM BENEFITS All the information about Prescribed Minimum Benefits (PMBs) is available on the Council for Medical Schemes website If you have any queries, please contact the us on Why do we have PMBs? The PMB legislation was created to ensure that all medical scheme members have access to continuous healthcare for specific conditions even if your annual limits have run out and regardless of the benefit option you have selected. You are entitled to at least the minimum specified treatment to manage your PMB condition. PMB legislation requires Bonitas to fund the diagnosis, treatment and care of: any emergency medical condition and a list of 270 groups of conditions known as Diagnosis Treatment Pairs (DTPs) which includes 25 common chronic conditions grouped on the scheme Chronic Disease List (CDL). The costs related to the diagnosis, treatment and care of PMB conditions are fully covered by medical schemes, provided a member follows the guidelines. When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors. This approach is called diagnosisbased. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor's rooms). To manage the treatment, medical schemes apply PMB formularies and protocols, which are largely based on the government's guidelines to manage these conditions. This is referred to as PMB level of care. What PMB conditions are covered by Bonitas? 1. Emergency medical conditions An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not provided, the emergency could result in damage to bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death. 2. Diagnosis Treatment Pairs (270 medical conditions) The Regulations to the Medical Schemes Act provide a long list of conditions identified as Prescribed Minimum Benefit conditions. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and indicates how these PMB conditions should be treated. It is important to note that it is not always possible to diagnose a condition before admitting a patient for treatment. However, if doctors suspect that the patient suffers from a condition that is a PMB condition, the medical fund will need to approve treatment in order for it to be paid correctly. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time. Member Guide 2014 Page 23

24 Here is an example of a DTP as it appears in the Medical Schemes Act: Code Diagnosis Treatment 109A Vertebral-dislocations/ fractures, open or closed with injury to spinal cord Repair/reconstruction; medical management; inpatient rehabilitation up to two months The 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories: PMB category Brain and nervous system Eye Ear, nose, mouth and throat Respiratory system Heart and vasculature (blood vessels) Gastro-intestinal system Liver, pancreas and spleen Musculoskeletal system (muscles and bones); Trauma NOS Skin and breast Endocrine, metabolic and nutritional Urinary and male genital system Female reproductive system Pregnancy and childbirth Haematological, infectious and miscellaneous systemic conditions Mental illness Chronic conditions Example Stroke Glaucoma Cancer of oral cavity, pharynx, nose, ear, and larynx Pneumonia Heart attacks Appendicitis Gallstones with cholecystitis Fracture of the hip Treatable breast cancer Disorders of the parathyroid gland End-stage kidney disease Cancer of the cervix, ovaries and uterus Antenatal and obstetric care requiring hospitalisation HIV/Aids and TB Schizophrenia Asthma, diabetes, epilepsy, hypothyroidism, ect No exclusions All medical schemes have a list of conditions, called exclusions, for which a member has no cover. An example of a Scheme Specific Exclusion would be cosmetic surgery. PMB diagnoses may not legally have Scheme Specific Exclusions applied to them. For example, if you contract septicaemia after cosmetic surgery, Bonitas has to provide healthcare cover for the treatment of the septicaemia because it is a PMB condition. The cost of the cosmetic surgery, however, remains an exclusion. PMB relates to the diagnosis of the condition, not how you got the condition. 3. The 25 chronic diseases list The Chronic Disease List (CDL) specifies medicine and treatment for the 25 chronic conditions that are covered under PMB: 1. Addison's disease 2. Asthma 3. Bipolar mood disorder 4. Bronchiectasis 5. Cardiac failure 6. Cardiomyopathy disease 7. Chronic obstructive pulmonary disorder (emphysema) 8. Chronic renal disease 9. Coronary artery disease (angina pectoris and ischaemic heart disease) 10. Crohn's disease 11. Diabetes insipidus 12. Diabetes mellitus types 1 & Dysrhythmias 14. Epilepsy 15. Glaucoma 16. Haemophilia 17. Hyperlipidaemia 18. Hypertension (high blood pressure) 19. Hypothyroidism 20. Multiple sclerosis 21. Parkinson's disease 22. Rheumatoid arthritis 23. Schizophrenia 24. Systemic lupus erythematosus 25. Ulcerative colitis Page 24 Member Guide 2014

25 Chronic Disease Lists (CDL) To manage risk and ensure appropriate standards of healthcare, treatment algorithms were developed for the CDL conditions. The algorithms, which have been published in the Government Gazette, list the minimum standards of treatment that Bonitas must pay for. If you have one of the 25 CDL diseases, Bonitas not only has to cover medication, but also a certain number of doctors' consultations and tests related to your condition. All medical schemes may make use of protocols, formularies (lists of specified medicines) and Designated Service Providers (DSPs) to manage this benefit, as Bonitas does. How do I apply for PMB benefits? Although the process is mostly automated and PMB conditions are identified through the ICD-10 codes reflected on your claims, you are welcome to apply for PMB telephonically via the Bonitas call centre or on the website on by logging into the secure area. 1. Chronic medicine All PMB chronic medicine is managed through the CMM programme as described on page 20 to Out of hospital benefits Out of hospital treatment is managed through PMB Care Plans which assigns you with a basket of care specific to your PMB condition. Care Plans are automated and will track the treatment of your conditions through the ICD-10 codes and will make sure that you receive the appropriate care by listing the type and number of services that are likely to be needed by a patient with your diagnosis and that Bonitas will cover. It includes out of hospital treatment such as doctor consultations, radiology and pathology tests. 3. In-hospital benefits In hospital benefits for PMB conditions are identified by the clinical coding used by the doctors and apply to the 270 DTPs & Emergencies. Treatment in hospital will also be guided by the Care Plans allocated to that condition or the appropriate PMB level of care as defined by your scheme. Please follow the normal steps to pre-authorise an in hospital visit and call Pre-Authorisation at least 2 days before your scheduled procedure or [email protected]. If a procedure is unplanned, such as in an emergency, please contact the pre-authorisation call centre on within a working day of admission. 4. Oncology benefits Not all oncology conditions are PMB conditions and those that are, are identified by the clinical coding used by the doctors. It is important to join the Oncology Benefit Management Programme so that you can benefit from the guidance and support you will receive from the Care Managers. See page 34 for more on Oncology. 5. HIV/AIDS benefits Apart from being specifically provided for by most schemes, HIV/AIDS is also a PMB condition and is included on the chronic conditions list. See page 31 for more information on the Aids for Aids programme. How will PMB be covered? As per legislation, you will be provided with at least the minimum treatment needed for you PMB condition. Your Fund will pay costs in full for PMB from your available benefit limits, for example, radiology services will pay from your Radiology annual sub-limit. Once your Fund limits are used up further services, for example as listed in your Care Plan or as clinically appropriate for your PMB condition, will continue to be paid from a risk pool. If you need further treatment for your condition your treating doctor will need to submit clinical motivation for assessment and approval. How to avoid rejected PMB claims: Check that your doctor (or any other medical service provider) has placed the correct ICD-10 code on your invoice. ICD-10 codes provide accurate information on your diagnosis and help the medical Fund to decide what benefits you are entitled to and how these benefits should be paid. ICD-10 codes must also be provided on medicine prescriptions and referral notes to other healthcare providers (e.g. pathologists and radiologists) who are not all able to make a diagnosis. Therefore, they require the diagnosis information from your referring doctor so that their claim to your medical Fund can also be paid correctly. Medical schemes are obliged by law to treat information about members' conditions confidentially. If my PMB claim is rejected who can I call? You can contact the Bonitas call centre to query the rejection. It is important to check that your medical practitioner has placed the correct codes on your invoice. Once diagnosed, please keep all your supporting documents on file as the operator may ask for this information when working on your claim. Additional conditions covered by Bonitas (both PMB and non-pmb) BonComprehensive In addition to the PMB conditions, the following 27 diseases are covered: 1. Acne 2. Allergic Rhinitis 3. Ankylosing Spondylitis 4. Attention Deficit Disorder (in children aged 5-18) 5. Behcet s Disease 6. Barrett s Oesophagus 7. Dermatitis 8. Eczema 9. Generalised Anxiety Disorder 10. Gastro-Oesophageal Reflux (GORD) 11. Gout 12. Huntington s Disease 13. Hypoparathyroidism 14. Myaesthenia Gravis 15. Narcolepsy 16. Neuropathies 17. Obsessive Compulsive Disorder 18. Osteoporosis 19. Paget s Disease 20. Panic Disorder 21. Pemphigus 22. Polyarteritis Nordosa 23. Post-Traumatic Stress Syndrome 24. Systemic Sclerosis 25. Pulmonary Interstitial Fibrosis 26. Tourette s Syndrome 27. Zollinger-Ellison Syndrome Although these conditions fall within the DTPs of the PMBs conditions, they are covered on BonComprehensive Option through a comprehensive formulary of medication from any service provider. Only a restrictive formulary is available on all other options apart from Standard Option and only if obtained through the Designated Service Provider. Member Guide 2014 Page 25

26 Standard In addition to the PMB conditions on page 24 the following 16 diseases are covered: Chronic Disease List 1. Acne 2. Allergic Rhinitis 3. Ankylosing Spondylitis 4. Attention Deficit Disorder children ages Barrett s Oesophagus 6. Behcet s Disease 7. Dermatitis 8. Eczema 9. Gastro-Oesaphageal Reflux (GORD) 10. Gout 11. Narcolepsy 12. Obsessive Compulsive Disorder 13. Panic Disorder 14. Post-Traumatic Stress Syndrome 15. Tourette s Syndrome 16. Zollinger-Ellison Syndrome Once the chronic limit is exceeded: Only medicines used to treat PMB diseases authorised by Medicine Management that fall within the protocols specified by Council will continue to be reimbursed. The Medicine Price List (MPL) will apply. Medicines must be obtained from a Designated Service Provider (DSP) and will be subject to the formulary. In formulary medicines, dispensed by the DSP, will be fully reimbursed. In formulary medicines, dispensed by providers other than the DSP, will be partially reimbursed and the member will be responsible for a 40% co-payment. Out of formulary medicines, dispensed by any provider, will be partially reimbursed and the member will be responsible for a 40% co-payment. Therefore a co-payment of 40% will be charged if medicine is not obtained from the DSP or is not part of the formulary. The co-payment is to be paid at the point of service. BonClassic 37 chronic conditions covered R8 200 per beneficiary Primary and BonSave Covers 25 chronic conditions (PMB) authorised by Chronic Medicine Management that fall within the protocols specified by Council. These medicines must be obtained from a Designated Service Provider (DSP) and will be subject to the Restrictive formulary. In formulary drugs, dispensed by the DSP, will be fully reimbursed (subject to the Medicine Price List where applicable). In formulary drugs, dispensed by providers other than the DSP, will be partially reimbursed and you will be responsible for a 40% co-payment. A co-payment of 40% will be imposed: If medicine is not obtained from the DSP or is not part of the Restrictive Formulary The co-payment is to be paid at the point of service In terms of legislation, the co-payment of PMB medicine may not be paid from savings account i.e. payment needs to be made from the member s own pocket Page 26 Member Guide 2014

27 HOSPITAL BENEFIT MANAGEMENT (HBM) Hospital Benefit Management's focus is improving the appropriateness and cost effectiveness of care, providing more healthcare value with the available benefits and getting members into registered facilities, treated by registered doctors, for acceptable forms of treatment, at appropriate levels of care, for a reasonable length of stay. The pre-authorisation process ensures added value for you by making sure the planned intervention is medical necessary and appropriate prior to the event or admission. This process can be initiated by you, your medical practitioner or the hospital. The request can be submitted telephonically, electronically ( and via the web) and by fax. Pre-authorisation of hospital admissions includes: Confirmation of membership Evaluation of the request against Fund rules Evaluation of the request against clinical guidelines and protocols Authorisation of hospital admission where appropriate MHRS guidelines for admissions, length of stay and level of care are continuously updated, and draw on international and local best practice. Extensive use is made of evidence-based guidelines and protocols which are impartial, reliable and generally accepted. When do I need to pre-authorise? Applying for a pre-authorisation reference number (PAR) As soon as a visit or admission to a hospital (out-patient or inpatient), CT scan, MRI scan or radio-isotope study is planned. It is preferable to do this at least two days before you go to hospital. Also includes: Renal clinic admissions for dialysis Doctors' rooms procedures in lieu of hospitalisation Physical rehabilitation care in rehabilitation facilities Drug & Alcohol rehabilitation care in specific facilities Hospice admissions Oxygen therapy at home All specialised radiology In the event of emergency treatment / admission to hospital over a weekend, public holiday or at night you MUST contact the pre-authorisation call centre on the first working day after the incident. Failure to obtain pre-authorisation for a planned event or authorisation on the first working day after an emergency event will mean that you are liable for a penalty according to the rules of your scheme. Member Guide 2014 Page 27

28 How do I pre-authorise? You can apply for pre-authorisation: 1. Online Go to Click on the drop down arrow in the Login box at the top right hand corner of the Bonitas website and select member to log into the secure area. Then click on the pre-authorisation button. 2. By - [email protected] (please ensure that your request is accompanied by all the relevant information to finalise your request) 3. By calling (08:30am - 5:00pm Monday to Friday) excluding public holidays. What information must I have ready when I apply for a PAR? Membership number Member or beneficiary name and date of birth Date of admission and the proposed date for the operation Name of the doctors and their telephone and practice numbers, if available Name of the hospital with their telephone and practice numbers, if available In the event of a CT scan, MRI procedure, etc, the name of the radiological practice is also required. Ask your doctor for: All the relevant procedure codes All the relevant associated medical diagnosis codes What must I keep record of when I apply for a PAR? The unique PAR number The initial approved length of stay The status of all the codes Will I receive any communication about my pre-authorisation? You will receive a letter confirming your pre-authorisation either via or post. This letter contains a number of disclaimers printed at the end. Please make sure you take note of and understand these disclaimers as they reflect your Fund rules. If you are unclear, please discuss the disclaimers with your treating doctor. Important information to know What happens if I have to stay in hospital for longer than the initial approved length of stay? Ensure that your doctor, the hospital case manager or a family member informs the case management department (via at [email protected]) of the extended length of stay. This is usually the responsibility of the hospital. If there is a clinical reason for the stay, your Fund will approve the extra days. If not, you will be liable for the costs of the non-approved days and treatment. Do co-payments still apply on procedures performed in-hospital? Any procedure that is stipulated in your Fund rules as attracting a co-payment will still attract one while you are in-hospital. Your diagnosis or treatment plan will not change this. Why are some requests for pre-authorisation declined? Some of the pre-authorisation requests will be declined if: The planned procedure is not covered by your medical plan as specified in the Fund rules. The planned procedure is not in line with the acceptable treatment standards for a particular medical condition. The appropriate clinical information has not been received. An inactive membership status or similar issues with membership status. Case management While you are in hospital, case managers ensure that appropriate care is provided at all times and that appropriate discharge planning takes place where clinically indicated and where benefits are available. This takes place according to the Fund rules, clinical protocols and funding guidelines. When extended length of stay or level of care is requested, the case manager will request supporting information to be able to make an informed clinical decision. If there is any doubt at all, a medical advisor will assist and motivation might be requested from your treating provider, if needed. All changes in initial approvals are communicated to the hospital and treating provider. With long term cases, your family members may also be involved. BONCOMPREHENSIVE AND STANDARD OPTIONS ONLY What is the Centre for Diabetes and Endocrinology? The Centre for Diabetes and Endocrinology (CDE) is a holistic, multi-specialist Diabetes Centre in Houghton, Johannesburg. The Centre manages diabetes by using a team approach that includes diabetes specialists, diabetes educators, a dietician, podiatrists, a clinical psychologist, as well as exercise specialists if necessary. In addition, the Centre trains healthcare professionals in the principles and practice of good diabetes care, and acts as the central office for a nationwide network of over 240 affiliated Centres for Diabetes. These accredited centres are contracted to provide all the benefits of the diabetes management programme, which is a complete diabetes management package. The objectives of the CDE Programme are to: Achieve and maintain good diabetes control Reduce hospital admissions for diabetes Improve the quality of life for people with diabetes Focus on wellness and health Reduce the acute and chronic costs associated with diabetes management Page 28 Member Guide 2014

29 The package covers: 1. All necessary consultations With a doctor specially trained in diabetes management (a minimum of two full examinations per year) With a Diabetes Educator (a minimum of two education sessions per year) With a dietician (one per year) 2. Annual screening visits Ophthalmologist for eye screening Podiatrist for foot screening 3. Hospitalisation for acute diabetes emergencies Hypoglycaemic coma Ketoacidosis, etc. 4. All necessary laboratory tests for diabetes monitoring and management 5. All diabetes medication Insulin Tablets for Diabetes 6. Diabetes supplies Needles and syringes Testing strips Blood glucose monitors Additional benefits A 24-hour telephone Hotline, staffed by trained personnel, for diabetes emergencies. This prevents unnecessary hospitalisation. The number will be given to you by your diabetes centre at your first consultation. All medication and accessories to manage your Diabetes are supplied by your doctor. Discretionary benefits where considered clinically necessary: A visit to a clinical psychologist can be arranged for counselling A consultation with an exercise physiologist (biokineticist) can be arranged for advice on exercise if you are a member of Bonitas Medical Fund on the BonComprehensive or Standard Option you have Diabetes, you can register with CDE and receive these benefits at no extra charge. Bonitas Medical Fund offers you this programme because it is now known that good Diabetes control reduces the incidence of diabetes complications (blindness, kidney failure, heart attacks, etc.) and hospitalisation for Diabetes. How do I join this programme? If you have diabetes and belong to Bonitas Medical Fund, on the BonComprehensive or Standard Options, you can join in one of three ways: 1. If you are already a patient at a Centre for Diabetes, contact the centre to be signed on to the programme. 2. Ask your family doctor to refer you to the closest Centre for Diabetes where you can be registered with the programme. 3. If you wish to remain with the doctor who is currently treating your diabetes ask him / her to contact the CDE central office in Houghton, Johannesburg. They will then provide information and the doctor will be trained and accredited as a preferred provider within the Centre for Diabetes network. Conditions of membership You are responsible to attend the minimum number of consultations as set out above and failure to do so may disqualify you from membership of the programme. The programme only applies to the management of diabetes carried out directly by a Centre for Diabetes or an accredited doctor. Blood tests must be done by a laboratory appointed by the Centre and hospital admissions must be approved by the Centre. Exclusions It is important to note that the programme does not include the provision of non-diabetes-related medication or the cost of management of diabetes complications such as eye problems, kidney failure and cardiovascular disease. These must be claimed from your Medical Fund. The Centre for Diabetes and Endocrinology Monday to Friday 8:30am-5pm Tel: (011) Fax: (011) [email protected] They will provide you with the contact details of the closest Centre for Diabetes branch where you can register and receive your treatment. Pathology management Pathology services are vital as healthcare professionals are able to determine the exact nature of our health problems and monitor the effects of prescribed treatments. Private pathology laboratories are a world where technology reigns supreme; laboratories are manned 24 hours a day by a multitude of qualified technologists, nurses, computer management systems and pathologists producing over test results per day in South Africa. Pathology testing is an indispensable and valuable branch of medicine, but is also relatively expensive. Your GP or specialist is able to order, on your behalf, any combination of tests, which may be paid virtually automatically if no pathology management takes place. Healthcare professionals are often unaware of the high cost of these tests and there is a tendency to order tests in profiles or groups. Three of four such requests can result in an account in excess of R1 000, when a few carefully selected tests would have been as effective. Keeping pathology costs down It is always our aim to make sure that healthcare costs are kept as affordable as possible, while ensuring quality care. With this in mind, most costs are managed, including pathology costs. Pathology management is a pathology claims assessment programme and is used to manage pathology costs. Member Guide 2014 Page 29

30 No pre-authorisations are necessary, but all pathology accounts are audited to ensure correct billing practices. Decisions or clinical interventions taken by pathology management are in accordance with the Medical Scheme industry guidelines. Should a motivation be required for certain tests according to these standards, the pathology laboratory will be contacted directly. Tests are important tools but they have limitations. More test do not necessarily mean better care. By keeping the following in mind you can help to manage and preserve your benefits: 1. When you visit your healthcare professional, make sure that you give him a complete description of your symptoms; don t just answer questions. 2. If you have a chronic problem, ask if it is necessary to repeat all the tests, which may have been recently ordered. 3. In the case of allergy, make sure a complete history is taken. A general allergy test can sometimes cost as much as R3 000, where a specific allergy test, for example cat hair allergy, costs only R When a doctor requests a group of tests, ask if all the tests are necessary for your care and ask if individual tests will suffice. 5. In all cases, if a single test result is abnormal and more testing is required, the pathologist will phone your doctor and discuss your case and further testing can be arranged on the original specimen retained by the laboratory. 6. Keep a copy of the request note in case there is a disagreement regarding test ordering or the account, or if you are expected to pay a portion of the amount due. Once you have agreed to the tests, ask your healthcare professional if there is any preparation required prior to the test. E.g. fasting, no exercising or no smoking, which may affect the results of certain tests. The next time you see your healthcare professional, as to review your results and if possible, take notes for your own records. Most importantly, if your GP send you to a specialist, ask your GP to send your test results to the specialist or ask the laboratory to copy the results to the specialist. It is estimated that 15% of all pathology test costs are as a result of unnecessary repeat tests. Should you receive an account from a laboratory for the balance of an amount not paid due to a pathology management intervention, you may contact your call centre to find out if it is a valid claim. This advice is offered to enable you, together with your healthcare professional, to play an important role in controlling your healthcare costs. It is important to remember that pathology management fully supports the doctor/patient relationship. Page 30 Member Guide 2014

31 AID FOR AIDS (AFA) HIV/AIDS Living with HIV does not have to be frightening; treatment and care is available that can allowmost people living with HIV to lead healthy and productive lives for many years. Action and information Know your status: the first step is to find out whether you have been infected with HIV and what you can do to protect your loved ones and stay healthy. Medicines are available to suppress the HI virus, while vitamins, good nutrition and exercise can play a critical role in keeping your body strong and healthy. Starting treatment at the right time can result in the medicines working well, which will improve the quality of life and decrease the risk of serious infections or other complications. Our Aid for AIDS programme can help you access benefits to assist you with the best way of managing HIV infection and enable you to live positively. We can help you to manage your condition Your medical fund has a benefit amount specifically for HIV/AIDSrelated medicine. This benefit amount is used to pay for: medicine to prevent the virus from multiplying and keep it dormant (antiretroviral therapy or ART) medications to protect you against illnesses such as TB and flu vitamins to boost your immune system regular monitoring tests Even if you do not need ART because it is still too early, it is important to register on the programme so you can access all the other benefits and keep healthy. Your condition will stay confidential Every effort is made to keep members HIV status confidential. The staff members at our Aid for AIDS unit have all signed confidentiality agreements and work in a dedicated unit. They use separate telephone, fax, and private mailbag facilities. Patients need to use these facilities to maintain confidentiality. You must register on our Aid for AIDS programme If your test shows you are HIV-positive you must register with Aid for AIDS as soon as possible to make use of this benefit. Telephone them in confidence on and ask for an application form. Your doctor can also contact Aid for AIDS on your behalf and register you on the programme. It is very important to register on the programme as soon as you know your status! By registering even before medication is needed, you will gain access to invaluable support and guidance which will prepare you mentally and emotionally for the journey ahead. You will also make it easy for AfA and your doctor to introduce you to treatment at exactly the right time. This is critical for improving the effectiveness of the medicine and making sure that you get the best possible outcome for your health. Member Guide 2014 Page 31

32 After you have registered After you receive the application form, you and your doctor must complete it and return it to the Aid for AIDS programme by using the confidential, toll-free fax-line number on the form. Your doctor can also register you by telephone once you have given consent and agreed to registration in this manner. A highly-qualified medical team will check your medical details and, if necessary, discuss cost-effective and appropriate treatment with your doctor. Once treatment has been agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the approved medicine, as well as the regular tests that need to be done to ensure that the drugs are working correctly and safely. What the Aid for AIDS programme offers you Aid for AIDS is a complete HIV disease management programme that offers both members and beneficiaries: Medicine to treat HIV (including drugs to prevent mother-to-child transmission and infection after sexual assault or needle-stick injury) at the most appropriate time Treatment to prevent opportunistic infections like certain serious pneumonias and TB Regular monitoring of disease progression and response to therapy Regular monitoring tests to pick up possible side-effects of treatment Ongoing patient support via a team of trained and experienced counselors Clinical guidelines and telephonic support for doctors Help in finding a registered counselor for face to face emotional support If you are exposed to HIV infection through sexual assault or through accidental exposure (bodily fluids or contaminated needles), please ask your doctor to contact Aid for AIDS to authorise special antiretroviral medicine to help prevent possible HIV infection. It is best to take this medicine as soon as possible (within hours) after exposure. If the incident putting you at risk occurs over the weekend, make sure you get the necessary medication on time. You or your doctor can contact the Aid for AIDS programme on the Monday morning to arrange authorisation of the drugs for payment by your medical fund. Tel: Fax: [email protected] Website: Mobisite: Please call me: Page 32 Member Guide 2014

33 BENEFICIARY RISK MANAGEMENT (BRM) Beneficiary management programmes The ultimate goal of Beneficiary Risk Management (BRM) programmes is to improve quality of life and promote costeffective treatment by encouraging our members and their beneficiaries to take responsibility for their own health and wellness. The beneficiary's healthcare professional is involved as far as possible. The benefits of the programme include: Making sure your benefits are used appropriately Encouraging you to take care of your overall health, lifestyle and quality of life Providing you with information to help you manage your conditions Referring you to appropriate healthcare professionals; and Assisting your treating doctor in the management of the condition. How do you know if you are eligible to join a Care programme? If you have been identified, a care manager will contact you telephonically to enroll you, there is no need for you to contact us. Beneficiary Risk Management contact details BRM call centre: [email protected] Are you a candidate for a care programme? We identify eligible candidates by taking the following into account: Does your condition appear to be particularly severe? Are you having difficulty controlling the condition? Have you been hospitalised as a result of the condition? Member Guide 2014 Page 33

34 ONCOLOGY DISEASE MANAGEMENT Oncology Disease Management It is important that on diagnosis of cancer, you are registered on the Oncology Disease Management Programme and that your treatment plan is forwarded to the clinical team, as all oncology treatment is subject to pre-authorisation and case management. Once the Oncology Disease Management team has received your details, disease information and proposed treatment plan, it will be captured. The treatment plan is then reviewed and if necessary, a member of the clinical team will contact your doctor to discuss more appropriate or cost effective treatment alternatives. After the treatment plan has been assessed and approved, an authorisation will be sent to your treating doctor. You will also be issued with an authorisation letter. These letters will indicate the treatment authorised, the approved quantities and the period of validity of the authorisation. Please make sure that your doctor advises the Oncology Disease Management team of any change in your treatment, as your authorisation will need to be reassessed and updated. Failure to do so may result in your claims being rejected or paid from the incorrect benefit (e.g. savings or other day to day benefits) as there will not be a matching oncology authorisation. Who should register on the programme? Only patients who have been diagnosed with cancer and are actively receiving treatment should register with the programme. What steps do I follow in order to register on the programme? On diagnosis, your treating doctor should fax or a copy of your treatment plan to the oncology case manager who will then take the process forward. How can I update my authorisation if treatment changes? Any changes to treatment, treatment dates or your treating doctor, need to be communicated to the oncology management team. If we are not informed of the changes, your claims may be rejected or paid from the incorrect benefits, as the claims will not match to the authorisation on the administration system. Updates to your treatment plan can be ed or faxed to the oncology management team, as per the contact details at the end of this document. How to obtain authorisation for associated treatment 1. Surgery/procedures/hospital admissions: If you need to be admitted to hospital for administration of chemotherapy or radiotherapy, please contact the Oncology Management Department directly as usual. Surgery or related procedures are covered from the hospital benefits and not the oncology benefit, so you will need to get a pre-authorisation from Page 34 Member Guide 2014

35 the Hospital Pre-authorisation Department. To pre-authorise for these procedures, please use the contact details listed at the end of this document. 2. Specialised radiology (including PET scans): If you require specialised radiology, such as CT, MRI or PET scans, you will need an additional authorisation from the Oncology Management Department for it to be covered from your oncology benefit. When applying for a specialised radiology authorisation, the following information is required: membership number, dependant number, requesting doctor practice number, radiology practice number, codes to be charged and estimated cost, and reason for the scan. If you need an authorisation for a PET scan, your doctor must complete the PET scan form which is available at all PET scan units. 3. Hospice, private nursing and medical admissions: If you need services such as home nursing or hospice, you need to contact the Hospital Pre-authorisation Department. You can also contact this department if you have complications like dehydration, excessive vomiting, or need to be hospitalised for pain control. Should you need more information, you are welcome to contact the Oncology Management Department on: Call centre: [email protected] Fax: Member Guide 2014 Page 35

36 BONITAS GP AND SPECIALIST NETWORK The time for change is now Bonitas Medical Fund is always investigating new ways to help you, our valued member, save money while receiving only the best health care service available today. It is for this reason, that we have introduced a more cost effective way of managing healthcare for our members The GP Network. What is it? The new GP Network will provide you with access to over pre-approved general practitioners at fixed rates. This would put healthcare back in your hands, giving you more control over your health and medical expenses. Why are we doing this? Before, we saw thousands of our members visiting many different GPs for different reasons. This resulted in duplicate testing, duplicate costs, and unnecessary visits with expensive specialists but most notably of all, a defined increase in out of pocket expenses. Visiting one dedicated GP will make it easier for us to help you gain a solid, ongoing understanding around the state of your health. Because our Network GPs don t charge over the scheme tariffs and will never charge you additional consultation fees, you will not have to face out of pocket expenditure. How does it work? All Bonitas members can make use of the Bonitas GP Network of doctors. Choosing to visit a GP in the network, provides members with the guarantee that they will not be charged more than the Bonitas tariff. Standard and Primary Option members Out of hospital benefits for Standard and Primary Option members have been enhanced to optimise this important initiative. An out of hospital GP benefit has been created to ensure that Standard and Primary Option members have more than adequate access to their GP co-ordinator of care. Your GP benefit does not form part of your day-to-day benefit. Instead, out of hospital pathology and radiology are included in the day to day benefit. Members may still visit GPs that are not part of the Network. However, the benefit amount available for visiting a non-network GP is significantly lower than for visiting a GP registered on the Network. GPs on the Network will aim to improve the health of their patients by making use of the funds available in the day to day benefit. Where appropriate the GPs will prescribe medication, send the patient for radiology or pathology tests etc. In addition, the GP will refer patients to a specialist where appropriate and is responsible for ensuring that he/she gets feedback from the specialist on the outcome of the specialist consultation. Page 36 Member Guide 2014

37 Members will note the introduction of a Specialist Referral Management System, which requires that all members obtain referral from their GP in order to visit a specialist. Specialist referral ensures appropriate care Your GP should be the first person to advise you about your healthcare needs. Not only does your GP understand your illness, but he/she also knows which type of specialist doctor is best for you to see. The GP will assist you in consulting with the right specialist should you need to, saving you both time and money. Please be sure to remind your GP to call the call centre to obtain an automated specialist referral authorisation number, via the IVR (Interactive Voice Response) system. Important points to be aware of when visiting a specialist Out of hospital specialist visits will only be paid if a specialist authorisation referral number is created by your GP; either via the IVR system, the Provider call centre or the Medscheme website. Emergencies requiring specialist visits will be allowed, provided your GP creates a specialist referral authorisation number, within 72 working hours. If you are referred by one specialist to another, please remember to contact your GP to create a specialist referral authorisation number. The following exceptions are applicable: Children under 2 years of age, may see a Paediatrician directly without receiving a specialist referral authorisation number, created by your GP. Maternity care by a gynaecologist does not require a specialist referral authorisation number from your GP. One gynaecologist visit per year is permitted per female beneficiary, for a general check-up; thereafter your GP is required to give you a specialist referral authorisation number. What happens if your benefits run out? The Bonitas GP Network is the scheme s Designated Service Provider (DSP), for the provision of Prescribed Minimum Benefits (PMBs). So should you run out of benefits, you may access care by visiting a GP on the Network. A co-payment of 40% will apply to consultations outside of the Network, once benefits are exhausted. Specialist visits above limits will only be authorised if a specialist referral authorisation number is created by a GP. How to access a Bonitas Network GP? You can access the Network, and based on your area requirement, you will be provided with a choice of the closest Network GP, by: Calling or Visiting How can you as a valued member help to grow this GP Network? Ask your trusted family doctor to join the network if they haven t already done so. Contact the member call centre and give your GP s name, practice number and contact details. Our team will follow up with them. Now it makes more sense than ever for your GP to join the network. The benefit of being a Bonitas GP Network doctor ensures that your GP receives preferential treatment to a non-network GP. How would your GP benefit by joining the GP Network? Doctor s receive enhanced fees for providing cost-effective quality care. If you visit a network GP, you will have 3 times the benefits available, compared to seeing a non-network GP. If your benefits are exceeded for Prescribed Minimum Benefit (PMB s) diseases, Bonitas will pay your chosen Network GP as per the PMB funding guidelines. Please refer to the list below for specialist types that will require a GP referral authorisation number: Dermatologist Neurosurgeon Gynaecologist Orthopaedic Surgeon Pulmonologist ENT Specialist Physician Rheumatologist Specialist Physician, e.g. Paediatrician Endocrinologist Paediatric Cardiologist Gastroenterologist Plastic Surgeon Neurologist Surgeon Cardiologist Urologist Psychiatrist The Bonitas GP Network provides you with access to over 5200 GPs at affordable rates. This puts healthcare back in your hands by ensuring accessible optimum quality standards of care, maintenance of good health, and giving you more control over your health and medical expenses. Bonitas Specialist Network To increase your access to affordable, quality healthcare, Bonitas partnered with healthcare professionals to create the GP Network, a comprehensive list of over General Practitioners. On 1 September 2012, the new Bonitas Specialist Network was launched, giving you access to over specialists nationally. If you are a member on the Standard, Primary, BonSave, BonClassic and BonEssential Options, the Specialist Network will provide you with access to specialist services at a negotiated tariff for both in and out of hospital costs. The benefit of this initiative will result in your claim being paid in full without you paying any shortfall. If you have a prescribed minimum benefit (PMB) condition and your day to day benefit limits have been exhausted, you can continue to consult with a Specialist within the Bonitas Specialist Network without incurring any co-payments. (The services for these conditions will be subject to the guidelines as contained within the Medical Schemes Act). If you would like to know if your Specialist is part of the Bonitas Specialist Network, visit our website on or call or send an to [email protected]. Member Guide 2014 Page 37

38 Additional benefits Free flu vaccine To help our members beat the winter blues, Bonitas offers you and your registered dependants free flu vaccinations. Visit a dispensing doctor, or your local pharmacy to be vaccinated. Note: If you ask your doctor to supply and administer the vaccine - it will be free, but you will be charged a consultation fee by your doctor which will be paid from your day to day benefit/savings. Pharmacy Advised Therapy (PAT) You don t always have to go to a doctor to get medicine. Your pharmacist can prescribe and dispense certain medicines without a doctor s prescription. If you have a mild sore throat, cold, a mild cough or anything similar, ask your pharmacist to dispense appropriate medicine and clearly write PAT on your claim. The cost of this claim is deducted from your normal day-to-day benefit. You don t have to pay for this out of your pocket and you save on the cost of a consultation with your doctor. Management of fraud and abuse Fraud continues to be a major concern to most medical aid companies, and schemes lose millions of Rands as a result of paying fraudulent claims. As you know, the greater the losses through fraud, the higher your contributions are to help cover this loss. Bonitas Medical Fund has measures in place to detect and manage fraud and abuse of benefits. You can help to combat fraud by anonymously contacting our fraud hotline if you are aware of any practitioner or patient abusing the system. Fraud hotline: Page 38 Member Guide 2014

39 CORPORATE SOCIAL INVESTMENTS 1. Bonitas House Call Bonitas House Call is a weekly medical television talk show that brings the doctor into the viewer's home, discussing topics that seek to educate, inform and provide advice on health matters. This programme offers free medical advice and tips as well as focusing on specific medical issues that are in the public domain. The show focuses on medical issues across the board with an extensive array of experts, bringing an ordinary South Africans directly to the medical experts in an interactive and educational environment. The show is hosted by a well known radio and TV personality Dr. Victor Ramathesele, who takes viewer's calls and SMSs which he then responds to. Each week, this show looks at different medical topics and incorporate inserts tackling a variety of health-related issues, and enabling further interaction with the public. Bonitas House Call is produced by Izwi Multimedia and is screened at 9am, every Saturday on SABC2. 2. Free State Stars FC The history and the successes of South African soccer attracted Bonitas to consider and entertain discussions that would lead to a mutual beneficial relationship with specifically Free State Stars. Bonitas recommitted to this sponsorship after they qualified back to the Premier Soccer League in The contract entered into was for three years and would be renewed as and when it lapsed. Soccer brags with a highest television audiences and the greatest number of spectators when compared to other sporting codes. These are great measures of success which Bonitas a brand would like to be associated with. Because football is the most loved sport in South Africa, the target audience cuts across all ages, all genders and all LSMs. With such a rich history and achievements, Free State Stars FC has been instrumental in increasing the Bonitas brand image, equity, awareness and preference. Obviously with more budget allocated on leveraging, this sponsorship property is bound to take the Bonitas brand to even more levels of new heights. The media exposure received from Free State Stars exceeds the investment amount by far. All the matches played received good coverage on radio, print and television. 3. Comrades Marathon Comrades Marathon is the world's largest and oldest ultramarathon race of approximately 90 km staged in Kwazulu-Natal and runs between the cities of Durban and Pietermaritzburg. The route direction of the race alternates each year between the "up" run (87 km) starting from Durban and the "down" run (89 km) starting from Pietermaritzburg. Bonitas has identified Comrades Marathon as a partner in promoting physical fitness through running not only for the benefit of our members but the entire population of South Africa and beyond. Bonitas came in as one of the official sponsors of this race that has gained popularity over the years. Winning brands like to be associated with events that personify common values. Beyond promoting healthy living, our involvement also represents values that Bonitas strongly believes in i.e. tenacity, perseverance, sportmanship, loyalty and fellowship. Over and above this, Bonitas has been supporting underprivileged Member Guide 2014 Page 39

40 runners coming from places far away from Durban to run the race. Comrades Releaf is a Bonitas sponsored programme championed by Wildlands Conservation Trust, one of the official Comrades Marathon charities. Its purpose is to build a fundraising and awareness campaign for the Sustainable Communities project (previously Indigenous Trees for Life) around the Comrades Marathon event. Every year, trees are planted in the four days leading up to the event, one for every runner. This campaign raises in the region of R every year for the programme. Comrades Marathon has become part of the Bonitas brand and has delivered more exceedingly towards the expectation. The media exposure and total value of the sponsorship has been steadily accelerating over the years. It is therefore my recommendation that the sponsorship contract be renewed. 4. Bonitas Pro Cycling This is a ten-man band of professional cyclists led by South African cycling legend, Malcolm Lange. This team has dominated the national cycling scene for the past recent years. 5. The Bonitas Academy This endeavour aims to improve and enhance the skills of GPs to assist in controlling healthcare costs and improving the quality of care provided to patients. We believe upskilling GPs (such that they are equipped to perform relatively minor procedures in their rooms rather than referring these cases to specialists and hospitals) will have a significant impact on reducing health costs. Our ultimate objective is to increase the GPs ability to manage patients more professionally and clinically appropriately at primary care level and decrease the unnecessary referral to secondary care and hospital care. Page 40 Member Guide 2014

41 BONITAS EXCLUSION LIST Aromatherapy Ayurvedics Herbalists Iridology Reflexology Therapeutic Massage Therapy Appliances, devices and procedures not scientifically proven Back rests and chair seats Bandages and dressings (except medicated dressings) Cardiac assist devices e.g. Berlin Heart Diagnostic kits, agents and appliances unless otherwise stated except for diabetic accessories electric tooth brushes Humidifiers Ionisers and air purifiers Orthopaedic shoes and boots, unless specifically authorised; Pain relieving machines, e.g. TENS and APS; stethoscopes Sphygmomanometers (blood pressure monitors) Oxygen hire or purchase, unless authorised Infertility - Medical and surgical treatment, which is not included in the Prescribed Minimum Benefits in the Regulations to Act 131 of 1998 Maternity - 3D and 4D Scans Anabolic steroids and immunostimulants unless Prescribed Minimum Benefits Contraceptives, oral, parenteral, foams, IUCD s and when used for skin conditions Cosmetic preparations, emollients, moisturizers, medicated or otherwise, soaps, scrubs and other cleansers, sunscreen and suntanning preparations, medicated shampoos and conditioners, except for the treatment of lice, scabies and other microbial infections and coal tar products for the treatment of psoriasis Erectile dysfunction and loss of libido medical treatment Food and nutritional supplements including baby food and special milk preparations unless prescribed for lifethreatening malabsorptive disorders and if registered on the relevant managed healthcare programme Slimming preparations for obesity Smoking cessation and anti-smoking preparations Tonics, evening primrose oil, fish liver oils, multi-vitamin preparations and/or trace elements and/or mineral combinations (except for registered products that include haemotinics and those for use by infants and pregnant mothers) All benefits for clinical trials unless pre-authorised by the relevant managed healthcare programme Medicines used specifically to treat alcohol and drug addiction, unless PMB Sleep therapy Epilation treatment for hair removal Hyperbaric oxygen therapy except for anaerobic life threatening infections, Diagnosis Treatment Pairs (DTP) 277S and specific conditions pre-authorised by the relevant managed healthcare programme. Coloured and other cosmetic effect contact lenses, and contact lens accessories and solutions Optical devices which are not regarded by the relevant managed healthcare programme, as clinically essential or clinically desirable except on BonSave and Member Guide 2014 Page 41

42 BonComprehensive option Sunglasses Organs and haemopoietic stem cell (bone marrow) donations to any person other than to a member or dependant of a member on this Fund Art therapy X-rays performed by chiropractors Chiropractor benefits in hospital MRI scans ordered by a general practitioner, unless there is no reasonable access to a specialist Positron Emission Tomography except on BonComprehensive and PET plus PET-CT for screening on all options Bone densitometry performed by a general practitioner or specialist not included in the Fund credentialed list CT colonography (virtual colonoscopy) for screening MDCT Coronary Angiography for screening If application for a pre-authorisation reference number (PAR) for specialised radiology procedures is not made or is refused, no benefits will be payable All screening that has not been pre-authorised or is not in accordance with the Fund s policies and protocols Bilateral gynaecomastia Breast augmentation Breast reconstruction - unless mastectomy following cancer and pre-authorised; Breast reductions unless medically necessary and pre-authorised Erectile dysfunction surgical procedures Gender re-alignment for personal reasons and not directly caused by or related to illness, accident or disease Genioplasties as an isolated procedure Keloid surgery, except following burns and there is evidence of gross functional impairment Obesity surgical treatment with the exception of certain bariatric surgical procedures performed for life threatening morbid obesity by a multidisciplinary team in accordance with an agreed protocol in a credentialed centre of excellence when preauthorised, but not including post-operative plastic and reconstructive surgery Otoplasties Pectus excavatum / carinatum Revision of scars Rhinoplasties for cosmetic purposes Uvulo-palatal pharyngoplasty (UPPP and LAUP) Appointments which a beneficiary fails to keep Autopsies Cryo-storage of foetal stemcells and sperm Holidays for recuperative purposes Travelling expenses Veterinary products Robotic assisted surgery Balloon Sinuplasty on Primary, BonEssential, BonClassic and BonSave Carmustine Wafers for the treatment of malignant Gliomas Page 42 Member Guide 2014

43 BONITAS CONTACT DETAILS CONTACT US: Discover more about how we can help you to get the best healthcare you need at a price you can afford. Visit We re always there for you just a call away. You can visit, or dial us anytime with any query or emergency and we ll help you so you can live a better life while we take care of the details. BONITAS CUSTOMER SERVICE MON-FRI 08H30-17: (CHARGED AT LOCAL RATES WHEN IN SOUTH AFRICA) BONCAP CUSTOMER SERVICE WEB [email protected] MON-FRI 08H30-17:00, (CHARGED AT LOCAL RATES WHEN IN SOUTH AFRICA) [email protected] POSTAL ADDRESS BONITAS MEDICAL FUND, PO BOX 1101 FLORIDA GLEN, 1708 PHYSICAL ADDRESS 37 CONRAD DRIVE, FLORIDA NORTH, 1709 FRAUD HOTLINE BLOEMFONTEIN: CAPE TOWN: DURBAN: LEPHALALE: KATHU: NORTHAM: PORT ELIZABETH: POLOKWANE: PRETORIA: ROODEPOORT: RUSTENBURG: SECUNDA: VEREENIGING: JOHANNESBURG: Shop C7, 1 st Floor, Middestad Centre, c/o Charles and West Burger Street, Bloemfontein Icon Building, Ground floor, corner Long Street and Hans Strijdom Avenue, Cape Town 3rd Floor, 67 Old Fort Road, Durban Onverwacht Business, Mienie Building, Block C, Walter Sisulu Avenue, Lephalale 6 Rietbok Street, Kathu, Northern Cape 180 Botha Steet, Northam Block 6, Greenacres Office Park, 2 nd Avenue, Newton Park, Port Elizabeth Ground Floor, Bonitas House, 22 Hans van Rensburg Street, Polokwane Ground Floor, Benstra Building, 473B Church Street, Arcadia, Pretoria 37 Conrad Road, Florida North, Roodepoort 141 Fatima Bhayat Street, Rustenburg Grand Palace, Unit 82, 2302 Heinis Street, Secunda 36 Merriman Avenue, Ground Floor, Vereeniging Mathomo Mall, 115 Main Street, Marshalltown, Johannesburg HOSPITAL AND SPECIALISED RADIOLOGY AUTHORISATIONS: 08h30-17h00 Mon-Fri Fax: (authorisations only) [email protected] CHRONIC MEDICINE AUTHORISATIONS: 08h30-17h00 Mon-Fri [email protected] Postal Address: PO Box Pinelands AID FOR AIDS PATIENT CARE LINE: SMS (call me): h30-17h00 Mon-Fri Doctor and Pharmacist Line: Fax: [email protected] Web: ONCOLOGY MANAGEMENT: 08h30-17h00 Mon-Fri Fax: [email protected] Web: PHARMACY DIRECT: 07h30-17h00 Mon-Fri Fax: /1/2/3 or [email protected] Web: OPTOMETRY: 08h00-17h00 Mon-Fri [email protected] Web: INTERNATIONAL TRAVEL BENEFIT: [email protected] /9000 DENTISTRY: 08h00-16h30 Mon-Fri [email protected] Fax: Web: CENTRE FOR DIABETES AND ENDOCRINOLOGY (CDE): 08h30-17h00 Mon-Fri Fax: / [email protected] Web: ER24: 08h00-16h30 Mon-Fri [email protected] Claims: [email protected] Web: MyCare: 08h00-17h00 Mon-Fri [email protected] Fax: Member Guide 2014 Page 43

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