BESTmed Medical Scheme

Transcription

1 BESTmed Medical Scheme An overview of for 2011 Members Who is BESTmed? BESTmed is an open, registered medical scheme, administered by Sanlam Healthcare Management (SHM). SHM is a wholly-owned subsidiary of Sanlam Life Insurance Limited, one of South Africa s leading financial services groups, with an enviable track record of providing products and services that embody their values of trust, honesty, integrity and caring. BESTmed has been providing superior healthcare cover to thousands of South Africans for the past 46 years and is a non-profit medical scheme. Like Sanlam, BESTmed continually strives to offer the best, with value-for-money products supported by superior client service to ensure that your dealings with BESTmed are efficient and to your satisfaction.

2 BESTmed quick facts: BESTmed has a reserve ratio of 33% (above the legal requirement of 25%). This means that it is a strong scheme and its risk management is expertly and responsibly managed. BESTmed is among the top 10 open medical schemes, with a principal membership base of more than members. BESTmed offers ten uniquely structured options, which are Rand-for-Rand the best value compared to many large, open medical schemes. Sanlam s incomparable industry expertise and managed healthcare is superior to many open medical schemes, giving you peace of mind that BESTmed is in the best hands. BESTmed manages its option increases prudently in order to prevent year-on-year excessive increases. Service provider accounts are paid on a weekly basis. page 2

3 How does BESTmed work? BESTmed s core can be broadly categorised as follows: In-hospital Medicine Preventative care Health Management Programmes This covers procedures and surgery done in hospital. These expenses are usually high, but infrequent. Inhospital expenses are paid by BESTmed up to the Scheme tariff. There are some limits for certain procedures, which are detailed in your option brochure. This includes consultations, procedures and medical expenses that take place out of hospital, e.g. GP and specialist consultations and procedures performed in a doctor s room. Depending on the option you choose, these expenses will be paid from: major medical benefit, or your medical savings account, or your bonus account, or your day-to-day limit, or you will be liable for payment yourself. Please see your option brochure for more details. Prescribed medicine listed in the formulary is paid by BESTmed. Chronic medicine for the 26 Chronic conditions will be paid in full by BESTmed provided you obtain preauthorisation and register for the Chronic Medicine Benefit. Chronic medicine listed in the formulary for non-cdl conditions will be paid by BESTmed, but you may have a copayment. See your option brochure for details. This covers immunisations and examinations to prevent you from getting sick. Please see your option brochure for more details. These programmes are aimed at managing your wellbeing and treatment if, for example, you: have cancer, are HIV positive or have AIDS, have a chronic condition, are pregnant, etc. You must register for the relevant programme/s in order to receive the. This category of also includes the management of your care in hospital. Please go to co.za and click on Managed care for comprehensive information about these programmes. Please refer to the inside of this brochure for a comparison of the ten options available in page 3

4 2011 Healthcare offering We all have different needs when it comes to healthcare. You may seldom visit a GP, but when you have to go to hospital unexpectedly, you want peace of mind that you have cover to pay for in-hospital treatment. That s why BESTmed Medical Scheme offers you a range of choices to suit your personal circumstances. BESTmed s and services are, on a Rand-for-Rand basis, the best value when compared to many large, open medical schemes. BESTmed s range of options for 2011 has been designed by members for members to give you flexibility and choice over the level of medical you choose to meet your healthcare needs. What you select will depend on what you re looking for. You may be young and single and need the peace of mind that a comprehensive hospital plan brings, or you may need comprehensive medical cover for the whole family. Our range of ten options has been carefully structured and can be classified into three broad categories to give you the choice you are looking for at a price you can afford. Category 1 offers comprehensive hospital with limited savings to pay for out-of-hospital expenses. The options in this category are Beat 1, Beat 2 and Beat 3. Category 2 offers comprehensive hospital, but with more savings options to cover extensive out-of-hospital expenses. The options in this category are BonusPlus, Best Gold, Millennium Comprehensive, Topcare and Best Platinum. Category 3 offers a comprehensive hospital benefit with out-of-hospital provided by designated network providers only. The options in this category are Best Gold Select and BluePrint. Once you have selected the category that meets your broad healthcare needs, you can then choose an option that provides the specific you are looking for. The table below gives you an overview of the offered by each option. You can visit for more comprehensive information on each option before making your selection. You will receive a brochure with detailed information about the offered by the option you select. page 4

5 Category 1 Benefits Beat 1 Beat 2 Beat 3 In-hospital Private hospital costs are paid at 100% of the BESTmed tariff (pre-authorisation must be obtained).some sub-limits apply for certain procedures. Unlimited cover is provided for Prescribed Minimum Benefits in State facilities. Out-ofhospital You pay for all out-of-hospital, day-to-day medical expenses, e.g. GP and specialist visits, etc. You pay for all out-of-hospital expenses from your medical savings account. When your medical savings account is exhausted, you pay for them yourself. You pay for out-of-hospital expenses from your medical savings account. When your medical savings account is exhausted, you pay for them yourself. Basic dentistry according to BESTmed protocol, limited optometry services, MRI & CT scans are paid from scheme funds. Savings account Savings equal to 15% of your total annual contribution are available at the start of the benefit year to pay for medical expenses, e.g. GP visits, medicine, etc. Savings equal to 15% of your total annual contribution are available at the start of the benefit year to pay for medical expenses, e.g. GP visits, medicine, etc. Chronic medicine Chronic medication is provided for diseases on the Chronic. Co-payment of 35% for nonformulary Chronic medication is provided for diseases on the Chronic. Non-CDL medication is payable from your medical savings account. Co-payment of 35% for nonformulary Chronic medication is provided for diseases on the Chronic plus 5 non- CDL conditions with a 15% copayment up to the annual limit. Co-payment of 35% for nonformulary You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed. Preventative care (*Subject to BESTmed protocols) programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documen-tation Based Care)*. programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documen-tation Based Care)*, Basic/preventative dentistry. programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documentation Based Care)*, Basic/preventative dentistry. Copayments R1 000 on all endoscopic investigations if performed in hospital. If performed in doctor s rooms, no co-payment. R1 000 on all endoscopic investigations if performed in hospital. If performed in doctor s rooms, no co-payment. R1 000 on all endoscopic investigations if performed in hospital. If performed in doctor s rooms, no co-payment. page 5

6 Category 2 Benefits In-hospital Out-ofhospital Savings account Chronic medicine Preventative care (*Subject to BESTmed protocols) Copayments BonusPlus Best Gold Millennium Comprehensive Topcare Platinum Private hospital costs are paid at 100% of the BESTmed tariff (pre-authorisation must be obtained).some sub-limits apply for certain procedures. Unlimited cover is provided for Prescribed Minimum Benefits in State facilities. from your medical savings account until exhausted, then overall annual limit up to sub-limits, then your bonus account. Savings equal to 22% of your total monthly contribution are available each month. Unused monthly savings are transferred to the bonus account after four months. Chronic medication is provided for diseases on the Chronic plus 15 non-cdl conditions with a 15% co-payment up to the annual limit. Co-payment of 35% for non-formulary from your annual overall limit up to limit or benefit sublimits. When annual limit or a sub-limit is reached, further expenses will be for your own account. Chronic medication is provided for diseases on the Chronic plus 31 non-cdl conditions with a 15% co-payment up to the annual limit. Co-payment of 25% for non-formulary from your medical savings account first until you reach the threshold. When the threshold is reached, the expenses are then paid from the above-threshold up to the specified sub-limits. Savings equal to 17% of your total annual contribution are available at the start of the benefit year to pay for medical expenses.. Chronic medication is provided for diseases on the Chronic plus 31 non-cdl conditions with a 15% co-payment up to the annual limit. Co-payment of 25% for non-formulary from your annual overall limit up to limit or benefit sublimits. When annual limit or a sub-limit is reached, further from your medical savings account. Savings equal to 18% of your total annual contribution are available at the start of the benefit year to pay for medical expenses once you ve reached your overall limit or a particular sub-limit. Chronic medication is provided for diseases on the Chronic plus 31 non-cdl conditions with a 15% co-payment up to the annual limit. Co-payment of 25% for non-formulary You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed. programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documen-tation Based Care)*, Basic/preventative dentistry, HIB titre, PAP smear*, Mammogram. programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documentation Based Care)*, Basic/preventative dentistry, HIB titre, PAP smear*, Mammogram. programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documentation Based Care)*, Basic/preventative dentistry, HIB titre, PAP smear*, Mammogram. programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documentation Based Care)*, Basic/preventative dentistry, HIB titre, PAP smear*, Mammogram. from your annual overall limit up to limit or benefit sublimits. When annual limit or a sub-limit is reached, further by you. Chronic medication is provided for diseases on the Chronic plus 45 non-cdl conditions with a 15% co-payment up to the annual limit. Co-payment of 20% for non-formulary programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documentation Based Care)*, Basic/preventative dentistry, HIB titre, PAP smear*, Mammogram, Lipogram*, Prostate Specific Antigen*. page 6

7 Category 3 Benefits Best Gold Select BluePrint In-hospital Out-ofhospital Private hospital costs are paid at 100% of the BESTmed tariff (pre-authorisation must be obtained).some sub-limits apply for certain procedures. Unlimited cover is provided for Prescribed Minimum Benefits in State facilities. services are provided by the ONECARE network and paid from your annual overall limit up to limit or benefit sub-limits. When annual limit or a sub-limit is reached, further by you. Primary care services are to be obtained from the ONECARE network provider. services are provided by the Prime Cure network. Savings account Chronic medicine Chronic medication is provided for ONECARE formulary conditions plus 45 non-cdl conditions up to the annual limit. Co-payment of 25% for non-formulary Chronic medication is provided for Prime Cure formulary CDL and non-cdl conditions. You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed. Preventative care (*Subject to BESTmed protocols) Copayments programme*, Paediatric immunisation, Back rehabilitation programme (provided by Documen-tation Based Care)*. programme*. R2 500 on all laparoscopic procedures. R3 000 on hip and knee replacements. R2 500 on prostate procedures. R2 500 on procedures for prolapse/incontinence. R2 500 on arthroscopy other than acute trauma. R2 000 on endoscopy investigations primarily in hospital. page 7

8 Contributions for 2011 OPTION P A C P+A P+A+C P+A+2C P+A+3C Beat 1 R738 R574 R311 R1 312 R1 623 R1 934 R2 245 Beat 2 R868 R675 R366 R1 543 R1 909 R2 275 R2 641 Beat 3 R1 353 R961 R522 R2 314 R2 836 R3 358 R3 880 BonusPlus R1 827 R1 283 R460 R3 110 R3 570 R4 030 R4 490 Best Gold R2 444 R2 395 R538 R4 839 R5 377 R5 915 R6 453 Millennium Comprehensive R2 470 R2 346 R864 R4 816 R5 680 R6 544 R7 408 Topcare < R R2 396 R1 918 R444 R4 314 R4 758 R5 202 R5 646 Topcare >R R2 878 R2 300 R482 R5 178 R5 660 R6 142 R6 624 Platinum R3 299 R3 299 R773 R6 598 R7 371 R8 144 R8 917 Best Gold Select R2 605 R2 605 R620 R5 210 R5 830 R6 450 R7 070 BluePrint < R R671 R671 R400 R1 342 R1 742 R2 142 R2 542 BluePrint R R R721 R680 R400 R1 401 R1 801 R2 201 R2 601 BluePrint R R R911 R696 R400 R1 607 R2 007 R2 407 R2 807 BluePrint > R R1 014 R775 R430 R1 789 R2 219 R2 649 R3 079 OPTION P+C P+2C P+3C P+2A P+2A+1C P+2A+2C Beat 1 R1 049 R1 360 R1 671 R1 886 R2 197 R2 508 Beat 2 R1 234 R1 600 R1 966 R2 218 R2 584 R2 950 Beat 3 R1 875 R2 397 R2 919 R3 275 R3 797 R4 319 BonusPlus R2 287 R2 747 R3 207 R4 393 R4 853 R5 313 Best Gold R2 982 R3 520 R4 058 R7 234 R7 772 R8 310 Millennium Comprehensive R3 334 R4 198 R5 062 R7 162 R8 026 R8 890 Topcare < R R2 840 R3 284 R3 728 R6 232 R6 676 R7 120 Topcare >R R3 360 R3 842 R4 324 R7 478 R7 960 R8 442 Platinum R4 072 R4 845 R5 618 R9 897 R R Best Gold Select R3 225 R3 845 R4 465 R7 815 R8 435 R9 055 BluePrint < R R1 071 R1 471 R1 871 R2 013 R2 413 R2 813 BluePrint R R R1 121 R1 521 R1 921 R2 081 R2 481 R2 881 BluePrint R R R1 311 R1 711 R2 111 R2 303 R2 703 R3 103 BluePrint > R R1 444 R1 874 R2 304 R2 564 R2 994 R3 424 P Principal member A Adult dependant C Child dependant page 8

9 Choosing a suitable option Your choice of option should offer the right cover to meet the medical needs of you and your family for the next year. It may help to look back at your claims for the past year to see where your highest claims were, as well as to consider any upcoming procedures or life-stage events (e.g. starting a family) that could affect your need for medical cover. In addition, consider how much you can afford to pay for your medical scheme cover. You can also consider the questions below to help you make your decision. What day-to-day do you need? These are usually the smaller medical expenses that occur more often, such as visits to your doctor or dentist. BESTmed offers a range of day-to-day cover options to suit you and your family s daily medical needs. Are you on chronic medication? This refers to prescribed medication that people with certain chronic conditions must use for long periods of time. As a member of BESTmed, your chronic medication will be covered if you suffer from a condition that appears on the list in terms of the Prescribed Minimum Benefits or the Chronic Disease List. There are also additional chronic on certain options for conditions that are not covered under the Prescribed Minimum Benefits. You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed. There is a separate form to be completed by you and your service provider when applying for this benefit. Do you want a medical savings account? A medical savings account is one way of ensuring that money is available to settle out-of-hospital medical costs. BESTmed offers various savings account options across most of its benefit options. page 9

10 Managing your medical costs To a large extent, the financial health of a medical scheme is determined by the health of its members. While we understand that accidents and dread diseases cannot always be predicted and, in some cases prevented, there are things that you can do to keep yourself healthy and away from the doctor s consulting rooms. Maintaining a healthier lifestyle will help to preserve your medical for longer so you don t run out of during the year. The lives we live have a lot to do with how we feel about life and, more importantly, about the health of our bodies. Three vital aspects of a healthy lifestyle are: Diet: You ve heard or read it all before. But here are some of the good old healthy eating tips to keep in mind every day: Drink at least eight glasses of water a day. Eat three balanced and healthy meals a day don t forget lots of fresh fruit and vegetables! Watch those unhealthy snacks. Go easy on the sugars and fats. Exercise: Many of the health and weight problems that people suffer from today are due to lack of physical exercise. Try these tips to achieve a more active lifestyle without going to the gym! Park further away from the shopping centre and do some extra walking. Take the stairs and not the lift. Dance. Walk round the block or in the park walk the dog! Healthy mind: When it comes to changing your lifestyle and your behaviour the right attitude is critical to make you stick to the plans you put into action. Start by adopting a positive attitude to everything you do and remember to take time out now and then to enjoy something that you really love. Only you can choose to live a healthier life. Here s to a healthier you in 2011 with BESTmed! page 10

11 BESTmed Medical Scheme Disclaimer Whilst BESTmed has taken all reasonable care in compiling this summary, we cannot accept liability for any errors or omissions contained herein. Please note that should a dispute arise with regard to any benefit, the registered Rules of BESTmed as approved by the Registrar of Medical Schemes shall prevail. This benefit overview is pending the Registrar s approval. BESTmed CONTACT DETAILS: Call centre: Pre-authorisation: service@bestmed.co.za Website: Fax: Regional SHDS offices Gauteng Free State Western Cape Port Elizabeth East London/Mthatha KwaZulu-Natal Mpumalanga Limpopo Sanlam Healthcare Distribution Services (SHDS) is the marketing and distribution network of BESTmed.