benefits and rates brochure 2016 · brochure 2016. a medical scheme that is in great health hosmed...

BENEF I TS AND RATESBROCHURE

2016

A MEDICAL SCHEME THAT IS IN GREAT HEALTH

Hosmed Medical Scheme is an open Medical Scheme providing healthcare to more than 71 000 benefi ciaries nationally

For more than 27 years, Hosmed has provided healthcare cover to a variety of employment groups in both Local Governmentand the Private sector

CALL CENTRE0860 00 00 48

wellnesschronicdisease management

Free chronic diseasemanagement programme

on all options

Free wellness benefi tfor all benefi ciaries

on all options

Free maternityprogramme

on all options

Value for money

A wide range of competitive benefi ts andcontribution options

Traditional medical scheme with an easy tounderstand benefi t design

Provide sustained excellence and personalizedservice

National footprint

Healthy reserves

PP

P

P

PP

Accepted by all service providers on a national basis

You only pay for the fi rst 3 children

P

PUnlimited hospitalisation on all options for PMB conditions P

The collective value of the Hosmed day-to-day benefi ts per option is the best in the industryP

Hosmed offers dentistry, optical, pathology and radiology benefi ts PER PERSON, no matter how big the family is

P

HOSMED FACTS

1

R323

R354

R679

R860

R1 281

R1 602

R942

R1 404

R1 755

ESSENTIAL R0 – R7 000

R7 001 – R12 000

R12 001+

R359

R393

R1 405

R1 742

R1 635

R2 022

ACCESS R0 – R7 000

R7 001+

R367

R419

R1 622

R1 865

R2 345

R2 695

VALUE R0 – R7 000

R7 001+

R560R2 492R3 736

MONTHLY INCOME

PLUS R0+

MEMBER ADULT CHILD*

*Maximum 3 children per family chargedPictures for illustration purposes only

2016 CONTRIBUTIONS

PREMIUM PENALTIES FOR PERSONS JOINING LATE IN LIFE:Premium penalties for persons joining late in life. Premium penalties will be applied in respect of persons over the age of 35 years, who were without medical scheme cover for the period indicated hereunder after the age of 35 years as follows:

1 – 4 @ 0.05 multiplied by the relevant contribution above



25 + years @ 0.75 multiplied by the relevant contribution above

“creditable coverage” means any period of verifi able medical scheme membership of the applicant or his or her dependant, but excluding membership as a child dependant, terminating two years or more before the date of the latest application for membership. Any years of creditable coverage which can be demonstrated by the applicant or his or her dependant shall be subtracted from his or her current age in determining the applicable penalty.

2

Scheme Tariff*: As defi ned in Scheme rule 4.9. (64)

The tariff determined or adopted by the Board in respect of the payment for healthcare services rendered to Benefi ciaries by service providers who are not subject to a DSP Tariff or a Negotiated Tariff, determined using the 2006 National Health Reference Price List (NHRPL) with the application of a year on year infl ationary increase, as contemplated in Rule 15.11

DSP Tariff*: As defi ned in Scheme rule 4.9. (26)

The fee determined in terms of an agreement between the Scheme and a service provider or a group of service providers in respect of the payment for the relevant health services

Negotiated Tariff*: As defi ned in Scheme rule 4.9. (51)

A tariff negotiated and agreed ad hoc for services rendered between the Scheme and a healthcare service provider for services rendered by the relevant service provider to the Scheme or to Benefi ciaries and which is different from the Scheme Tariff

Reference Price*: As defi ned in Scheme rule 4.9. (62)

The maximum reimbursable price for a list of generically similar or therapeutically equivalent products with a cost lower than that of the original medicine

ICON*: Independent Clinical Oncology Network

PRORATED BENEFITSApplicable if you join after the 1st of January of a benefi t year

STATUTORY PRESCRIBED MINIMUM BENEFITSNo Annual Limit

Services rendered payable at 100% of cost at DSP

3 MONTH GENERAL WAITING PERIODS Subject to the rights of interchangeability

12 MONTHS CONDITION SPECIFIC WAITING PERIOD FOR PRE-EXISTING CONDITIONS Subject to the rights of interchangeability

LATE CLAIMSClaims received later than the last day of the 4th month in which the service was rendered will not be covered

EMERGENCY MEDICAL COVER WHILST TRAVELING OUTSIDE OF SOUTH AFRICASubject to PMBs

100% of Scheme rates payable in RSA currency

Subject to completion of documentation prior leaving RSA

Subject to approval by scheme

PLUS PLAN

VALUE PLAN

ACCESS PLAN

ESSENTIAL PLAN

DEFINITIONS

3

HOSMED – WE CARE

Hosmed Medical Scheme offers a programme on ALL HOSMED OPTIONS for Chronic Disease List (CDL) conditions as Prescribed Minimum Benefi t (PMB) as listed below.

Please ensure that you register your condition at PHA to qualify for this benefi t:

• Call 0860 00 00 48 and select the Disease Management Option, or

• Download the Chronic Registration form on the Hosmed website and when completed return form by e-mailing to [email protected]

Benefi ts are subject to PMB’s

HIV / AIDS MANAGEMENT PROGRAMME

Treatment is subject to the treatment care plan and clinical protocols per CDL

100% of Scheme Tariff*Subject to Registrationon the Programme

chronicdisease management

CHRONIC DISEASE MANAGEMENT PROGRAMME (CDL)

Treatment is subject to the treatment care plan and clinical protocols per CDL

100% of Scheme Tariff*

Subject to Registrationon the Programme

PMB CHRONIC DISEASE LIST

Addison’s Disease

Asthma

Bipolar Mood Disorder

Bronchiectasis

Cardiac failure

Cardiomyopathy

Chronic Renal Disease

Chronic Obstructive Pulmonary Disease

Coronary Artery Disease

Crohn’s Disease

Diabetes Insipidus

Diabetes Mellitus Type I

Diabetes Mellitus Type II

Dysrhythmias

Epilepsy

Glaucoma

Haemophilia

HIV / AIDS

Hyperlipidaemia

Hypertension

Hypothyroidism

Multiple Sclerosis

Parkinson’s Disease

Rheumatoid Arthritis

Schizophrenia

Systemic Lupus Erythematosus

Ulcerative Colitis

I PLUS I VALUE I ACCESS I ESSENTIAL I

IN HOSPITAL BENEFITSPLUS

4

PRIVATE AND STATE HOSPITALS


Unlimited benefi ts for PMB conditions

Note: All admissions to hospitals and services listed below must be pre-authorised by the scheme / preferred provider or within 48 hours in the case of an emergency Failure to comply with this rule will result in a levy of R500 per admission. Please note that treatment protocols apply

ACCOMMODATION, THEATRE FEES, MEDICINES, INTENSIVE CARE


SURGICAL PROCEDURESINCLUDING GP AND SPECIALIST CONSULTATIONS


DIAGNOSTIC INVESTIGATIONS


Authorisation must be obtained prior to the examinationor within 24 hours in the case of an emergencyMRI / PET / CAT scans are subject to pre-authorisation

e.g. Radiology, Pathology, MRI / PET / CAT scans etc.

BLOOD TRANSFUSIONS


ONCOLOGY

100% of DSP Tariff*

Limited to R534 000 per person per annum

PMB* based on DSP ICON Enhanced Protocols and PMB Level of Care

Treatment subject to designated service provider guidelines and pre-authorisation

Subject to PMB’s as prescribed

DRUG & ALCOHOL REHABILITATION


Limited to R16 850 per family per annum

ORGAN TRANSPLANTS


PMB* based on Department of Health Protocols. Unlimited

DENTAL HOSPITALISATION


Anaesthetist and Hospital cost is payable from the hospital benefi t

Benefi t is payable from hospital benefi t only in the following cases:• Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved• Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only

MAXILLO-FACIAL AND ORAL SURGERY


Anaesthetist and Hospital cost is payable from hospitalisationRemoval of symptomatic impacted wisdom teeth ifpre-authorised as a day case only

All other procedures subject to PMB only

Subject to pre-authorisation, clinical protocols, formulary and PMB’s

All treatment in hospital, including accommodation, medicines, materials, procedures, consultations, and psychiatry / psychology therapy sessions

PSYCHIATRIC TREATMENT INCLUDING CLINICAL PSYCHOLOGY


Subject to 21 days per person per annum(Subject to PMB’s)

Non PMB’s – 14 days per family subject to a limit ofR19 800

Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan

RENAL DIALYSIS

100% of Negotiated Tariff*

Unlimited benefi ts for PMB admissions

Subject to Treatment Protocols and Formulary

STERILISATION / VASECTOMY


Sterilisation limited to R13 690 per person per annum

Vasectomy co-payment of R1 230 if procedure is done under General Anaesthetic in Major Theatre

LIMITED COLLECTIVELY AND SUBJECT TO AUTHORISATION BY: PRIVATE HEALTHCARE ADMINISTRATORS (PHA)

INTERNAL AND EXTERNAL PROSTHESIS100% of Negotiated tariff*


Sub-Limits:Subject to the overall limit and PMB protocols

PHYSIOTHERAPY & BIOKINETICS


5

BACK SURGERY / SPINAL PROCEDURESLimited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols. R25 000 per level subject to overall limit not being exceeded. Maximum 1 event per person per annum

JOINT REPLACEMENT(HIP, KNEE, SHOULDER AND ANKLE) Limited to one event per annum, unless sepsis or trauma R37 000 per annum (excludes cement)

APHAKIC LENSES R4 897 per lens

DIETICIAN & OCCUPATIONAL THERAPY100% of Scheme Tariff*

STEP DOWN FACILITIESIn lieu of hospitalisation100% of Negotiated tariff*

Limited to 14 days per person per annum

PRIVATE NURSINGIn lieu of hospitalisation100% of Negotiated tariff*


HYPERBARIC OXYGEN THERAPY75% of Scheme Tariff*


NEGATIVE PRESSURE WOUND THERAPY100% of Scheme Tariff*


MEDICATION FOR AGE RELATED MACULAR DEGENERATION70% of Negotiated tariff*

STEREOTACTIC RADIO-SURGERY100% of Scheme Tariff*Only Covered for Primary Central Nervous System Tumours

LAPAROSCOPIC HOSPITALISATION AND ASSOCIATED COSTS100% of Scheme Tariff*

Laparoscopic Hospitalisation & Associated costs will attract a 10 % co-payment except for the following circumstances where no co-payment will apply:• Purely diagnostic laparoscopy• Aspiration / excision ovarian cyst• Lap-cholecystectomy• Lap-apendicectomy for females• Repair of recurrent or bilateral inguinal hernias

FUSION, LAMINECTOMY AND DISCECTOMYIf the patient fails to comply with the conservative treatment program and goes for surgery without authorisation a co-payment of 30% on accommodation, medicines, consultations and procedures is applicableSubject to confi rmation that benefi ciary has completed a course of conservative back treatment

CARDIAC STENTS1 per lesion – maximum 3 lesionsBare metal stents: R12 000 per stentDrug eluting stents: R17 000 per stent

The following is subject to the overall prosthesis benefi t:

• Cardiac valves, Aortic stent grafts, peripheral aterial stents grafts, Single / dual pacemaker

• Cardiac resynchronization devices (CRT), Implantable Cardioverter Defi brillators (ICD) with Pacing Capabilities (CRT-D)Subject to state hospital protocols and PMB for secondary prevention only. Overall limits applies for primary prevention

• Internal sphincters and stimulators

• Neurostimulators / Internal nerve stimulator for Parkinson‘s Disease

• Cochlear implants

• Insulin pumps and monthly materials Children under 7 years of age only

UNLISTED PROSTHESISMaximum R15 000 subject to overall limit

REHABILITATION FACILITIES100% of Negotiated tariff*


CIRCUMCISION


In and out of hospital

O

NO OVERALL ANNUAL LIMIT

SUBJECT TO SUB-LIMITS NOT BEING EXCEEDED

OUT OF HOSPITAL BENEFITSPLUS

6

CONSULTATIONSOut-of-Hospital – including general practitioners and outpatient facilities100% of Scheme Tariff*

16 visits per person limited to 26 visits per family per annum

DIAGNOSTICINVESTIGATIONS

Subject to PMB’sand protocols


PATHOLOGY Limited to R4 360 per person per annum

RADIOLOGY Limited to R3 210 per person per annum

MRI / PET / CAT SCANSLimited to 2 scans per person per annum

Subject to pre-authorisation

ACUTE MEDICINESIncluding Material and Homeopathic Medicine

100% of Reference Price*

Limited to R4 800 per person and R9 400 per family per annum

PMB CHRONIC DISEASE LIST MEDICINES100% of Reference Price* Unlimited Benefi t initially payable from limit above

Subject to pre-authorisation, treatment protocols and medicine formulary*

PHARMACY ADVISED TREATMENT (PAT)Limited to R 975 per family per annum

Maximum R 191 per script

Included in acute limit aboveOver the Counter Medication

Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines

CONTRACEPTIVEBENEFIT


Subject to the contraceptive formulary and protocols

Subject to oral and injectable contraceptives only

CHRONICMEDICATION

OTHER CHRONIC (NON CDL) MEDICINES

100% of Reference Price*R12 600 per person limited to R24 060 per family per annum

Non formulary products will incur a 30% co-payment where these are obtained voluntarily by benefi ciariesChronic Medication to be obtained from Designated Service Provider (DSP)Subject to renewal of prescription every six months

PMB’s subject to registration and pre-authorisation with the schemes preferred provider (DSP)

CONSERVATIVE DENTISTRY (DENTIST AND DENTAL THERAPIST)


Unlimited

Subject to dentaltreatment protocols and

pre-authorisation forextensive treatment

ADVANCEDDENTISTRY


R5 840 per person limited to R7 360 per family per annum

Failure to obtain pre-authorisation will result in no payment

Subject to pre-authorisationby the scheme and treatment protocols

MAXILLO-FACIAL &ORAL, INCLUDINGDENTAL SURGERY

100% of Scheme Tariff*(included in Advanced Dentistry Limit)Benefi t is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only

Subject to PMB’s,pre-authorisation and

protocols

(e.g. Annual Consultations, Fillings,Preventative Dentistry, Extractions and X-rays)

(e.g. Crowns & Bridgework, Dentures, Root Canal Treatments, Orthodontics, removal of impacted wisdom teeth and Non-surgical Periodontics)

(Consultations, Surgical procedures and Operations)

No referral required for specialists visits

Included in benefi t above for consultations

SPECIALIST CONSULTATIONS

DENTAL BENEFIT MANAGEMENT BY: DENTAL RISK COMPANY (DRC)

PHARMACEUTICAL BENEFIT MANAGEMENT BY: MEDISCOR

7

SPECTACLE LENSES:IN AND OUT OF NETWORK

100% of DSP Tariff

R160 per lens – clear Aquity single vision or

R345 per lens – clear Aquity bifocal vision or

R636 per lens – clear Aquity multifocal vision

Fixed tints up to 35%

No benefi t for contact lenses if spectacles purchased

Limited to one pair of spectacles per person every24 months

EYE TESTS:IN AND OUT OF NETWORK100% of DSP Tariff Limited to R675 per person (in network)Limited to R280 per person (out of network)One claim per person every 24 monthsOne comprehensive consultation per person

CONTACT LENSES:IN AND OUT OF NETWORK

100% of DSP Tariff

R2 915 per person every 24 months

No claim for spectacles if contact lenses purchased.One claim per person every 24 months

FRAMES:IN AND OUT OF NETWORK100% of DSP Tariff R870 per personA frame cannot be claimed alone or with contact lenses.One claim per person every 24 months

ALTERNATIVE SERVICES


Collectively limited to R3 495 per family per annum

Medicine dispensed by the above providers are limited to the acute medication limit

REMEDIAL AND OTHER THERAPIES



PHYSIOTHERAPY OUT OF HOSPITAL


R2 340 per person limited to R3 750 per familyper annum

APPLIANCES

100% of Negotiated tariff*


• Stoma Care – Subject to a sub limit of R6 500 per family per annum

• Wheelchairs – one claim per person every 36 months subject to pre-authorisation

• Hearing aids – one claim per person every 24 months subject to pre-authorisation

Subject topre-authorisation

Homeopathy, Naturopathy, Chiropractor andPodiatry

Audiology, Speech therapy, Dieticians, Hearing Aid Acousticians, Occupational Therapy, Orthotics, Social Workers and Speech Therapy

Biokinetics & Physiotherapy

e.g. Hearing Aids,Wheelchairs and Calipers etc.

ALL OPTICAL BENEFITS: Contact the Schemes Preferred Provider Network for availability and Locality of Network Optometrists

OPTICAL BENEFIT MANAGEMENT BY: PREFERRED PROVIDER NETWORKS (PPN)

PLUS

8

AIR / ROAD AMBULANCE & EMERGENCY SERVICES

100% of Scheme tariff*

PSYCHOLOGY &PSYCHIATRY TREATMENT


R4 100 per person limited to R8 200 per family

Subject to PMB’s

INFERTILITY


HOSPICE AND PRIVATE NURSING


Subject to combined limit of a maximum period of 14 days per annum


protocols

Subject to PMB’s at State / Public Facilities

NON-EMERGENCYSubject to pre-authorisation beforehand

EMERGENCYSubject to pre-authorisation within 72 hours after the emergency. Inter-hospital transfers must be done by preferred provider only

The Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred

M = R10 960 M +1 = R23 090 M +2 = R25 200 = R27 750

OVERALL ANNUAL LIMIT FOR OUT OF HOSPITAL BENEFITS

ACUTE MEDICINES I ADVANCED DENTISTRY I ALTERNATIVE SERVICES (Homeopathy, Naturopathy etc.) IREMEDIAL & OTHER THERAPIES (Audiology, Dieticians etc.) I BIOKINETICS & PHYSIOTHERAPY I PSYCHOLOGY & PSYCHIATRY TREATMENT

OUT OF HOSPITAL BENEFITS

+M +3

HOSMED – WE CARE

PMB* Based on Clinical Protocols

BAMBINO PROGRAMME

00

HOSPITAL CONFINEMENT

NVD – Limited to 2 Nights and 3 days Caesarean – Limited to 3 Nights and 4 days

HOME DELIVERYby Registered Midwife

Limited to R6 000 / pregnancy. 100% of Negotiated Tariff

MATERNITY SONAR(S)

Limited to 3 2D sonar’s per pregnancy for In and Out of Hospital

MATERNITY VISIT(S)

Additional 5 visits per pregnancy (in addition to normal consultation limit)

ANTENATAL CLASSES

Limited to R477 per mother per annum

by Registered Nurse

IMMUNISATION BENEFIT

Immunisation as per the Immunisation schedule by the Department of Health up to 6 months of age

Available at Clicks and Dischem

1 FREE benefi t per person per annum as follows:

• Pap Smear for females over 18 years

• Mammogram for females over 40 years

• PSA for males over 40 years

• Cholesterol test over 20 years

• Flu vaccine

• Blood sugar test over 15 years

• Colon Cancer Blood Test over 50 years

• Blood Pressure Test

• HIV test

WELLNESS PROGRAMME

At 7 months of maternity, the scheme offers a free Maternity bag


Hosmed cares about its maternity mothers and this program aims to assist them during this time by providing advice and benefi ts

Designed around health screening, risk appraisal and personal wellness

wellness




Visit www.hosmed.co.zaand complete the

online registration form

HOW TO REGISTER

OR

Contact us on 0860 00 00 48

Contact your broker

OR

9

IN HOSPITAL BENEFITSVALUE

10



Unlimited benefi ts for PMB conditions

Note: All admissions to hospitals and services listed below must be pre-authorised by the scheme / preferred provider or within 48 hours in the case of an emergencyFailure to comply with this rule will result in a levy of R500 per admission. Please note that treatment protocols apply







Authorisation must be obtained prior to the examinationor within 24 hours in the case of an emergencyMRI / PET / CAT scans are subject to pre-authorisation


BLOOD TRANSFUSIONS


ONCOLOGY

100% of DSP Tariff*

Limited to R247 000 per person per annum

PMB* based on DSP ICON Standard Protocols and PMB Level of Care






ORGAN TRANSPLANTS


PMB* based on Department of Health Protocols. Unlimited



Anaesthetist and Hospital cost is payable from the hospital benefi t

Benefi t is payable from hospital benefi t only in the following cases:• Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved• Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only

MAXILLO-FACIAL AND ORAL SURGERY


Anaesthetist and Hospital cost is payable from hospitalisationRemoval of symptomatic impacted wisdom teeth ifpre-authorised as a day case only

All other procedures subject to PMB only

All treatment in hospital, including accommodation, medicines, materials, procedures, consultations, and psychiatry / psychology therapy sessions



Subject to 21 days per person per annum(Subject to PMB’s)

Non PMB’s – 14 days per family subject to a limit ofR17 600

Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan

RENAL DIALYSIS


Unlimited benefi ts for PMB admissions




Sterilisation limited to R13 000 per person per annum

Vasectomy co-payment of R1 230 if procedure is done under General Anaesthetic in Major Theatre



11

INTERNAL AND EXTERNAL PROSTHESIS100% of Negotiated Tariff*



PHYSIOTHERAPY & BIOKINETICS100% of Scheme Tariff*

BACK SURGERY / SPINAL PROCEDURESLimited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols. R20 000 per level subject to overall limit not being exceeded. Maximum 1 event per person per annum

JOINT REPLACEMENT(HIP, KNEE, SHOULDER AND ANKLE) Limited to one event per annum, unless sepsis or trauma R37 000 per annum (excludes cement)


DIETICIAN & OCCUPATIONAL THERAPY100% of Scheme Tariff*

STEP DOWN FACILITIESIn lieu of hospitalisation



PRIVATE NURSINGIn lieu of hospitalisation



HYPERBARIC OXYGEN THERAPY50% of Scheme Tariff*


NEGATIVE PRESSURE WOUND THERAPY100% of Scheme Tariff*


MEDICATION FOR AGE RELATED MACULAR DEGENERATIONSubject to PMB’s only

STEREOTACTIC RADIO-SURGERY100% of Scheme Tariff*Only Covered for Primary Central Nervous System Tumours

LAPAROSCOPIC HOSPITALISATION AND ASSOCIATED COSTS100% of Scheme Tariff*

Laparoscopic Hospitalisation & Associated costs will attract a 10 % co-payment except for the following circumstances where no co-payment will apply:• Purely diagnostic laparoscopy• Aspiration / excision ovarian cyst• Lap-cholecystectomy• Lap-apendicectomy for females• Repair of recurrent or bilateral inguinal hernias

FUSION, LAMINECTOMY AND DISCECTOMYIf the patient fails to comply with the conservative treatment program and goes for surgery without authorisation a co-payment of 30% on accommodation, medicines, consultations and procedures is applicableSubject to confi rmation that the benefi ciary has completed a course of conservative back treatment

CARDIAC STENTS1 per lesion – maximum 3 lesionsBare metal stents: R12 000 per stentDrug eluting stents: R17 000 per stent

The following is subject to overall prosthesis benefi t:

• Cardiac valves, Aortic stent grafts, peripheral aterial stent grafts, Single / dual pacemaker

• Cardiac resynchronization devices (CRT), Implantable Cardioverter Defi brillators (ICD) with Pacing Capabilities (CRT-D)Subject to state hospital protocols and PMB for secondary prevention only. Overall limit applies for primary prevention

• Internal sphincters and stimulators

• Cochlear implants

• Insulin pumps and monthly materials Children under 7 years of age only


REHABILITATION FACILITIES100% of Negotiated Tariff*


CIRCUMCISION



O

NO OVERALL ANNUAL LIMIT

SUBJECT TO SUB-LIMITS NOT BEING EXCEEDED

OUT OF HOSPITAL BENEFITSVALUE

12

CONSULTATIONSOut-of-Hospital – including general practitioners and outpatient facilities100% of Scheme Tariff*8 GP visits per person limited to 18 GP visits per family per annum




PATHOLOGY Limited to R2 385 per person per annum

RADIOLOGY Limited to R1 855 per person per annum

MRI / PET / CAT SCANSLimited to 2 scans per person per annum


ACUTE MEDICINESIncluding Material and Homeopathic Medicine

100% of Reference Price*

Limited to R3 040 per person and R6 170 per family per annum

PMB CHRONIC DISEASE LIST MEDICINES100% of Reference Price*. Unlimited Benefi t initially payable from limit above

Subject to pre-authorisation, treatment protocols and medicine formulary*

PHARMACY ADVISED TREATMENT (PAT)Limited to R600 per family per annum

Maximum R135 per script

Included in Acute limit aboveOver the Counter MedicationConsultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines

CONTRACEPTIVEBENEFITLimited to R1 200 per family per annum



CHRONICMEDICATION

OTHER CHRONIC (NON CDL) MEDICINES

100% of Reference Price*R5 936 per person limited to R11 980 per family per annum

Non formulary products will incur a 30% co-payment where these are obtained voluntarily by benefi ciariesChronic Medication to be obtained from Designated Service Provider (DSP)Subject to renewal of prescription every six months






ADVANCEDDENTISTRY


R3 820 per person limited to R5 460 per family per annum




100% of Scheme Tariff*(included in Advanced Dentistry Limit)Benefi t is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only


protocols




Member: 3 visits, Member +1: 5 visits, Member +2+: 7 visitsAll specialist consultation require GP referral or payment will be made at GP rates, except for:• Gynaecologists • Paediatricians




13

SPECTACLE LENSES:IN AND OUT OF NETWORK

100% of DSP Tariff

R160 per lens – clear Aquity single vision or

R345 per lens – clear Aquity bifocal vision or

R345 per lens – clear Aquity multifocal vision

Fixed tints up to 35%

No benefi t for contact lenses if spectacles purchased

Limited to one pair of spectacles per person every24 months

EYE TESTS:IN AND OUT OF NETWORK100% of DSP Tariff

Limited to R675 per person (in network)

Limited to R280 per person (out of network)One claim per person every 24 monthsOne comprehensive consultation per person


100% of DSP Tariff

R1 810 per person per annum

No claim for spectacles if contact lenses purchased.One claim per person every 24 months

FRAMES:IN AND OUT OF NETWORK100% of DSP Tariff

R580 per personA frame cannot be claimed alone or with contact lenses.One claim per person every 24 months

ALTERNATIVE SERVICES



Medicine dispensed by the above providers are limited to Acute Medication Limit

REMEDIAL AND OTHER THERAPIES



PHYSIOTHERAPY OUT OF HOSPITAL


R1 460 per person limited to R2 420 per familyper annum

APPLIANCES



• Stoma Care – Subject to a sub limit of R6 200 per family per annum

• Wheelchairs – one claim per person every 36 months subject to pre-authorisation

• Hearing aids – one claim per person every 24 months subject to pre-authorisation

Subject to pre-authorisation, failure to

obtain authorisation will result in no payment

Homeopathy, Naturopathy, Chiropractor andPodiatry

Audiology, Speech therapy, Dieticians, Hearing Aid Acousticians, Occupational Therapy, Orthotics, Social Workers and Speech Therapy

Biokinetics & Physiotherapy




VALUE

14




PSYCHOLOGY &PSYCHIATRY TREATMENT


R2 530 per person, limited to R6 360 per family

Subject to PMB’s


EMERGENCYSubject to pre-authorisation within 72 hours after the emergency. Inter-hospital transfers must be done by preferred provider only

The Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred.

M = R8 500 M +1 = R17 950 M +2 = R19 525 M +3 = R21 625

ACUTE MEDICINES I ADVANCED DENTISTRY I ALTERNATIVE SERVICES (Homeopathy, Naturopathy etc.) IREMEDIAL & OTHER THERAPIES (Audiology, Dieticians etc.) I BIOKINETICS & PHYSIOTHERAPY I PSYCHOLOGY & PSYCHIATRY TREATMENT

OVERALL ANNUAL LIMIT FOR OUT OF HOSPITAL BENEFITS

INFERTILITY


HOSPICE AND PRIVATE NURSING


Subject to combined limit of a maximum period of 14 days per annum


protocols


+

HOSMED – WE CARE


BAMBINO PROGRAMME


NVD – Limited to 1 Night and 2 days Caesarean – Limited to 2 Nights and 3 days

HOME DELIVERYby Registered Midwife

Limited to R5 000 / pregnancy. 100% of Negotiated Tariff

MATERNITY SONAR(S)


MATERNITY VISIT(S)

Additional 2 visits per pregnancy at GP or specialist(in addition to normal consultation limit)


Immunisation as per the Immunisation schedule by the Department of Health up to 6 months of age







• Flu vaccine


• Colon Cancer Blood Test over 50 years


• HIV test

WELLNESS PROGRAMME


BAMBINOO PROOGGRAMME



Designed around health screening, risk appraisal and personal wellness

wellness




00



HOW TO REGISTER

OR


Contact your broker

OR

15

16

ACCESSIN HOSPITAL BENEFITS

Exclusive DSP: Netcare Hospital Group


100% of DSP Tariff*

Unlimited benefi ts for PMB conditions,subject to Overall Annual Limit for Non-PMB

Subject to use of a Designated Service Provider (DSP) hospital network and prevailing hospital protocols

Note: All admissions to hospitals and services listed below must be pre-authorised by the scheme / preferred provider or within 48 hours in the case of an emergency

Failure to comply with this rule will result in a levy of R500 per admissions. Please note that treatment protocols apply

Failure to comply utilising a DSP provider will result in a 10% co-payment per admission except for emergency admissions


100% of DSP Tariff*





Subject to Clinical protocols and PMB’sNetwork Provider only

Pathology: R10 600 per familyRadiology: R10 600 per family

MRI / PET / CAT scans limited to 2 per person for In and Out of Hospital

Subject to pre-authorisation prior to the examination or within 24 hours in case of emergency


BLOOD TRANSFUSIONS

Subject to PMB conditions only

ONCOLOGY

100% of DSP Tariff*

Limited to PMB conditions only and subject to DSP ICON Standard Protocols and PMB level of Care





Subject to 21 Days per member per annum






ORGAN TRANSPLANTS


PMB* based on Department of Health Protocols



RENAL DIALYSIS


Unlimited benefi ts for PMB admissions and PMB levelof Care



Subject to PMB’s only

17

INTERNAL AND EXTERNAL PROSTHESIS






BACK SURGERY / SPINAL PROCEDURESLimited to PMB conditions as per prevailing public hospital protocols and regulations. Excludes disc prostheses and spinal cages. Second opinion required for non-trauma related surgery

Back Surgery for the above procedures will only be funded if the Scheme is satisfi ed that the benefi ciary has completed a course of conservative back treatment

JOINT REPLACEMENT(HIP, KNEE, SHOULDER AND ANKLE) Subject to overall limit and 1 procedure per person per annum unless PMB






HYPERBARIC OXYGEN THERAPY


NEGATIVE PRESSURE WOUND THERAPY


MEDICATION FOR AGE RELATED MACULAR DEGENERATION


LAPAROSCOPIC HOSPITALISATION AND ASSOCIATED COSTS


Laparoscopic Hospitalisation & Associated costs will attract a R5 300 co-payment

CARDIAC STENTSSubject to PMB only. Maximum of 3 stents as per public hospital protocols for STEMI. No benefi t for unstable angina or NSTEMI unless there is evidence of failed conservative medical treatment



• Cardiac resynchronization devices (CRT), Implantable Cardioverter Defi brillators (ICD) with Pacing Capabilities (CRT-D)

Subject to state hospital protocols and PMB for secondary prevention only. Overall limits applies for primary prevention

UNLISTED PROSTHESISMaximum R10 000 subject to the overall limit

REHABILITATION FACILITIES


CIRCUMCISION

100% of DSP Tariff* at DSP GPor 100% of Scheme Tariff* / at Specialist

Out of Hospital Only


O

INSULIN PUMPS AND MONTHLY MATERIALSChildren under 7 years of age only. Clinical motivation required with evidence of repeated admissions for documented hypo / hyperglycemia with brittle diabetes. Mediscor Medical Advisor recommendation required

ARTIFICIAL LIMBS AND EXTERNAL PROSTHESIS including artifi cial eyesPMB – UPFS rates applicable

DIETICIAN & OCCUPATIONAL THERAPY


OVERALL ANNUAL LIMIT

R1 000 000 per family

18

ACCESS

DAY HOSPITAL PROCEDURES

Procedures to be done at Designated Service Provider (DSP) hospital network


Co-payment still applicable to defi ned conditions

Subject to Scheme tariff*

SUBJECT TO PMB CONDITIONS ONLY:1. Tonsillectomy and adenoidectomy 2. Umbilical and Inguinal hernia repair 3. Colonoscopy 4. Cystoscopy 5. Gastroscopy and Oesophagoscopy6. Hysteroscopy 7. Myringotomy 8. Grommets 9. Termination of pregnancy10. Breast biopsy11. Cataracts12. Circumcision13. ERCP14. Haemorrhoidectomy15. Vasectomy16. Tubal Ligation17. Excision of extensive skin lesions or repair of wounds and skin grafts18. Dental procedures19. Repair nail bed & Removal of toenails20. Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger fi nger, ganglion, carpal tunnel syndrome21. Minor gynaecological procedures – cone biopsy, colpocopy, D&C

HOSPITAL PROCEDURES WITH CO-PAYMENT

R1 000 DEDUCTIBLE Except for PMB’s

1. Tonsillectomy and adenoidectomy 2. Umbilical hernia repair3. Colonoscopy4. Cystoscopy5. Conservative back treatment6. Functional nasal surgery7. Facet joint injections8. Flexible sigmoidoscopy9. Gastroscopy10. Hysteroscopy (not endometrial ablation)11. Myringotomy


1. Arthroscopy2. Hysterectomy 3. Percutaneous radiofrequency ablations4. Percutaneous rhizotomies


1. Back surgery including spinal fusions2. Joint replacements, for example hip and knee replacements 3. Laparoscopic Hospitalisation

IN HOSPITAL BENEFITS

19


CONSULTATIONS AND MEDICATIONOut-of-Hospital – including general practitionersand outpatient facilities

Collective Benefi t for Consultations and Medication:Main Member: R3 710, Adult: R2 650, Child: R1 590Subject to utilization of any GP within the DSP at 100% of DSP* TariffIf Non-DSP* GP is utilized voluntarily: 25% Co-payment payable by member per visit at 100% Scheme Tariff



100% of DSP Tariff*

RADIOLOGY & PATHOLOGY Limited to R1 800 per person per annum

Limited to Network provider only

Subject to PMB’s

MRI / PET / CAT SCANSLimited to 2 scans per person per annum, In & Out of Hospital as per hospital benefi t above

Referral by Network Provider Only


ACUTE MEDICINESIncluding Material and Homeopathic Medicine100% of Reference Price*

Subject to Collective Benefi t for Consultations and Medication above

Subject to medicine dispensed by the nominated DSP* GP and Medicine Formulary

PMB CHRONIC DISEASE LIST MEDICINES (CDL)100% of Reference Price*

Unlimited

Subject to pre-authorisation, treatment protocols and

medicine formulary*

PHARMACY ADVISED TREATMENT (PAT)Limited to R475 per family per annum

Maximum R85 per script

Subject to collective benefi t above for GP and Acute Medication benefi tOver the Counter MedicationConsultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines

CONTRACEPTIVEBENEFITLimited to R800 per family per annumSubject to the contraceptive formulary and protocols


CHRONICMEDICATION

Subject to Designated Service Provider (DSP), Treatment Protocols, Medicine Formulary and Registration of the Chronic Medicine by DSP GPProvider Network and Chronic Disease list Medicines only Subject to renewal of prescription every six months

Appropriate referral by GP / Specialist required



Limited to 3 visits per dependant and 5 visits per family

All specialist consultation require GP referral or payment will be made at GP rates


AUXILIARY BENEFIT

100% of Scheme Tariff*Limited to R1 590 per person and R5 300 per family per annum

APPLIANCES



In & Out of Hospital – PMB’s only


Combined benefi t for Alternative Services, Remedial and other therapies and Physiotherapy


GP AND DIAGNOSTICS BENEFIT MANAGEMENT BY: PRIME CURE HEALTH


20

ACCESSOUT OF HOSPITAL BENEFITS


100% of Scheme Tariff*Quantity Limitations Apply. Contracted Network Provider Only




Subject to PMB’s Only


protocols


ADVANCEDDENTISTRY






SPECTACLE LENSES:IN AND OUT OF NETWORK100% of DSP Tariff R160 per lens – clear Aquity single vision orR345 per lens – clear Aquity bifocal vision orR345 per lens – clear Aquity multifocal visionNo benefi t for fi xed tintsNo benefi t for contact lenses if spectacles purchased

Limited to one pair of spectacles per person every 24 months

EYE TESTS:IN AND OUT OF NETWORK100% of DSP Tariff Limited to R675 per person (in network)Limited to R280 per person (out of network)One claim per person every 24 monthsOne comprehensive consultation per person


100% of DSP Tariff R820 per person per annumNo claim for spectacles if contact lenses purchased.One claim per person every 24 months

FRAMES:IN AND OUT OF NETWORK100% of DSP Tariff R315 per personA frame cannot be claimed alone or with contact lenses.One claim per person every 24 months

AIR / ROAD AMBULANCE & EMERGENCY SERVICES100% of Scheme Tariff*

PSYCHOLOGY &PSYCHIATRY TREATMENTSubject to referral from GP or Specialist

Subject toPMB’s only

INFERTILITYSubject to PMB’s only

HOSPICE AND PRIVATE NURSINGSubject to pre-authorisation and protocols




EMERGENCYSubject to pre-authorisation within 72 hours after the emergency. Inter-hospital transfers must be done by preferred provider onlyThe Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred




00

HOSMED – WE CARE

wellness


BAMBINO PROGRAMME



Admissions only at DSP Hospital Network

MATERNITY SONAR(S)


MATERNITY VISIT(S)

3 Antenatal visits at a GP and 2 Additional Visits at a Gynaecologist


Immunisation as per the Immunisation schedule by the Department of Health upto 6 months of age











• Flu vaccine



• HIV test

WELLNESS PROGRAMME Designed around health screening, risk appraisal and personal wellness





HOW TO REGISTER

OR


Contact your broker

OR

21

ESSENTIALIN HOSPITAL BENEFITS

22


100% of DSP Tariff*

Unlimited benefi ts for PMB conditions,subject to Overall Annual Limit for Non-PMB

Subject to use of a Designated Service Provider (DSP) hospital network and prevailing hospital protocols

Note: All admissions to hospitals and services listed below must be pre-authorised by the scheme / preferred provider or within 48 hours in the case of an emergency

Failure to comply with this rule will result in a levy of R500 per admissions. Please note that treatment protocols apply

Failure to comply utilising a DSP provider will result in a 10% co-payment per admission except for emergency admissions


100% of DSP Tariff*





Subject to Clinical protocols and PMB’s

Network Provider only

Combined limit of R5 300 per person per annum

MRI / PET / CAT scans limited to 2 per person for In and Out of Hospital

Subject to pre-authorisation prior to the examination or within 24 hours in case of emergency





ORGAN TRANSPLANTS


PMB* based on Department of Health Protocols



BLOOD TRANSFUSIONS


ONCOLOGY

100% of DSP Tariff*

Limited to PMB conditions only and subject to DSP ICON Standard Protocols and PMB level of Care





RENAL DIALYSIS


Unlimited benefi ts for PMB admissions and PMB levelof Care



Subject to PMB’s only



Exclusive DSP: Netcare Hospital Group

Subject to 21 Days per member per annum

23

INTERNAL AND EXTERNAL PROSTHESIS






BACK SURGERY / SPINAL PROCEDURESLimited to PMB conditions as per prevailing public hospital protocols and regulations. Excludes disc prostheses and spinal cages. Second opinion required for non-trauma related surgery

Back Surgery for the above procedures will only be funded if the Scheme is satisfi ed that the benefi ciary has completed a course of conservative back treatment

JOINT REPLACEMENT(HIP, KNEE, SHOULDER AND ANKLE) Excluded unless PMB. Prosthesis limited to equivalent available in the state

APHAKIC LENSES Subject to PMB conditions





HYPERBARIC OXYGEN THERAPY

Subject to PMB conditions as per public hospital protocols

NEGATIVE PRESSURE WOUND THERAPY


MEDICATION FOR AGE RELATED MACULAR DEGENERATION


CARDIAC STENTSSubject to PMB only. Maximum of 3 stents as per public hospital protocols for STEMI. No benefi t for unstable angina or NSTEMI unless there is evidence of failed conservative medical treatment



• Cardiac resynchronization devices (CRT), Implantable Cardioverter Defi brillators (ICD) with Pacing Capabilities (CRT-D)

Subject to state hospital protocols and PMB for secondary prevention only. Overall limits applies for primary prevention


REHABILITATION FACILITIES


CIRCUMCISION

100% of DSP Tariff* at DSP GPor 100% of Scheme Tariff* at Specialist

Out of Hospital Only


O

INSULIN PUMPS AND MONTHLY MATERIALSChildren under 7 years of age only. Clinical motivation required with evidence of repeated admissions for documented hypo / hyperglycemia with brittle diabetes. Mediscor Medical Advisor recommendation required

ARTIFICIAL LIMBS AND EXTERNAL PROSTHESIS including artifi cial eyesPMB – UPFS rates applicable

DIETICIAN & OCCUPATIONAL THERAPY


OVERALL ANNUAL LIMIT

R740 000 per family

ESSENTIAL

24

DAY HOSPITAL PROCEDURES

Procedures to be done at Designated Service Provider (DSP) hospital network


Co-payment still applicable to defi ned conditions

Subject to Scheme tariff*

SUBJECT TO PMB CONDITIONS ONLY:1. Tonsillectomy and adenoidectomy 2. Umbilical and Inguinal hernia repair 3. Colonoscopy 4. Cystoscopy 5. Gastroscopy and Oesophagoscopy6. Hysteroscopy 7. Myringotomy 8. Grommets 9. Termination of pregnancy10. Breast biopsy11. Cataracts12. Circumcision13. ERCP14. Haemorrhoidectomy15. Vasectomy16. Tubal Ligation17. Excision of extensive skin lesions or repair of wounds and skin grafts18. Dental procedures19. Repair nail bed & Removal of toenails20. Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger fi nger, ganglion, carpal tunnel syndrome21. Minor gynaecological procedures – cone biopsy, colpocopy, D&C

HOSPITAL PROCEDURES WITH CO-PAYMENT


1. Tonsillectomy and adenoidectomy 2. Umbilical hernia repair3. Colonoscopy4. Cystoscopy5. Conservative back treatment6. Functional nasal surgery7. Facet joint injections8. Flexible sigmoidoscopy9. Gastroscopy10. Hysteroscopy (not endometrial ablation)11. Myringotomy


1. Arthroscopy2. Hysterectomy 3. Percutaneous radiofrequency ablations4. Percutaneous rhizotomies


1. Back surgery including spinal fusions2. Joint replacements, for example hip and knee replacements

EXCLUSIONS FOR HOSPITAL ADMISSIONS AND TREATMENT RELATED TO:

• Non-PMB Orthopaedics• Dentistry• Skin Disorders• Diagnostic Investigations• Elective Caesarean Deliveries (Emergency, Medical Necessity Only)• Cochlear Implants• Bunionectomy • Arthroscopy• Removal of Varicose Veins• Refractive Eye Surgery, Aphakic lenses• Non-Cancerous Breast Conditions• Stents• Infertility Treatment • Laparoscopic Hospitalisation

(In conjunction with the Overall Scheme Exclusion List and subject to PMB’s)

IN HOSPITAL BENEFITS


25

CONSULTATIONS AND MEDICATIONOut-of-Hospital – including general practitionersand outpatient facilities


GENERAL PRACTITIONERSNOMINATED DSP GPUnlimited visits & acute medication from selected3 Nominated DSP* from Network

NON-NOMINATED DSP GPNon-nominated GP’s limited to 1 visit per person and 2 visits per family per annum to a maximum of R740 including acute medication with a 20% co-payment



100% of DSP Tariff*

RADIOLOGYLimited to R740 per person per annum

Referral by Network provider only

MRI / PET / CAT SCANSLimited to 2 scans per person per annum and limited to In and Out of Hospital benefi t above

Referral by Network Provider Only


ACUTE MEDICINESIncluding Material and Homeopathic Medicine100% of Reference Price* Unlimited medication from selected Nominated DSP* from NetworkAcute Medication obtained from a Pharmacy:R950 per person limited to R2 650 per family per annum

PMB CHRONIC DISEASE LIST MEDICINES (CDL)100% of Reference Price*

Unlimited

Subject to pre-authorisation, treatment protocols and

medicine formulary*

PHARMACY ADVISED TREATMENT (PAT)Limited to R210 per family per annumMaximum R80 per scriptSubject to collective Acute Medication benefi t aboveOver the Counter MedicationConsultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines

CONTRACEPTIVEBENEFITLimited to R600 per family per annum



CHRONICMEDICATION

Subject to Designated Service Provider (DSP), Treatment Protocols, Medicine Formulary and Registration of the Chronic Medicine by DSP GP

Provider Network and Chronic Disease list Medicines only

Subject to renewal of prescription every six months



Limited to 3 visits per family per annum only on referral from nominated DSP GP



AUXILIARY BENEFIT


APPLIANCES

100% of Agreed CostLimited to R2 500 per family per annumIn & Out of Hospital – PMB’s only


Combined benefi t for Remedial and other therapies, Physiotherapy


PATHOLOGY Limited to R740 per person per annum

Network provider only

GP AND DIAGNOSTICS BENEFIT MANAGEMENT BY: PRIME CURE HEALTH


ESSENTIAL

26


100% of Scheme Tariff*Quantity Limitations ApplyContracted Network Provider Only






protocols


ADVANCEDDENTISTRY


Failure to obtain pre-authorisation will result in no payment.




SPECTACLE LENSES:IN AND OUT OF NETWORK100% of DSP Tariff R160 per lens – clear Aquity single vision orR345 per lens – clear Aquity bifocal vision orR345 per lens – clear Aquity multifocal visionNo benefi t for fi xed tintsNo benefi t for contact lenses if spectacles purchasedBenefi t applicable to members who utilize theScheme’s Preferred Provider Network Optometrists

Limited to one pair of spectacles per person every 24 months

EYE TESTS:IN AND OUT OF NETWORK100% of DSP Tariff

Limited to R620 per person (in network)

Limited to R280 per person (out of network)One claim per person every 24 monthsOne comprehensive consultation per person

CONTACT LENSES:IN NETWORK100% of DSP Tariff R445 per person every 24 monthsNo claim for spectacles if contact lenses purchased.One claim per person every 24 months

FRAMES:IN NETWORK100% of DSP Tariff

R160 per person only PPN Frame CoveredA frame cannot be claimed alone or with contact lenses.One claim per person every 24 months

AIR / ROAD AMBULANCE & EMERGENCY SERVICES100% of Scheme Tariff*

PSYCHOLOGY &PSYCHIATRY TREATMENTSubject to referral from GP or Specialist

INFERTILITYSubject to PMB’s only

HOSPICE AND PRIVATE NURSINGSubject to pre-authorisation and protocols




EMERGENCYSubject to pre-authorisation within 72 hours after the emergency. Inter-hospital transfers must be done by preferred provider onlyThe Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred






HOSMED – WE CARE

wellness


BAMBINO PROGRAMME



Admissions only at DSP Hospital Network

MATERNITY SONAR(S)


MATERNITY VISIT(S)

Unlimited consultations subject to DSP GP and Specialist consultations


Immunisation as per the Immunisation schedule by the Department of Health upto 6 months of age










• Flu vaccine



• HIV test

WELLNESS PROGRAMME Designed around health screening, risk appraisal and personal wellness



27




HOW TO REGISTER

OR


Contact your broker

OR

28

CHANGE OF PERSONAL DETAILS

GENERAL ADMINISTRATION

To allow the Hosmed Medical Scheme to confi rm benefi ts, authorisations and payment of claims, we need your latest within30 days of: • Changes to your Monthly Income• Changes to your marital status• Birth or legal adoption of a child • Any termination of dependants who are no longer entitled to membership

EASY CLAIMS PROCEDUREHosmed Medical Scheme aims to make the claims procedure as user-friendly as possible for its members. In most instances, service providers submit electronic claims to Hosmed Medical Scheme on behalf of their patients

Your responsibility is to ensure that:• Your service provider submitted your claim on your behalf within four months of the treatment date• You verify the treatment claimed by your service provider was indeed rendered. If any inaccurate services were claimed to inform Hosmed Medical Scheme of irregularities• You keep record of your expenditure and utilisation as per benefi t limits to ensure you do not exceed your benefi ts that will result in member payments• You follow-up on claim rejections if outstanding information is required to process the claims

CLAIMS PROCEDURE FOR CASH PAYMENTS If, for any reason, you should pay upfront for treatment rendered by your service provider that is covered by your Hosmed Scheme Option, you can claim this payment back. Make sure that you submit a detailed account and receipt for your payment with the following information: • Medical Aid Number• Member Member Name• Patient Name and Date of Birth• Dependant Number / Code• Provider Practice Number• Diagnosis Code (ICD10) and Procedure Name• Tariff Code and Amount Charged

Hosmed Call Centre: 0860 00 00 48General Enquiries: [email protected] Enquiries: [email protected] Enquiries: [email protected] Enquiries: hosmedfi [email protected] Enquiries: [email protected] Complaints: [email protected]

SERVICE PROVIDERS

HOW TO GUIDE

WEB-BASED QUERY FACILITYIf you have internet access you will be able to log into a secure site to view your:• Personal details• Claims history• Tax statements • Benefi t Limits• Remittance advices• Banking DetailsIf you would like to register, please visit www.hosmed.co.za, and follow the prompts for registration

If you require further information, please contact Client Services on 0860 00 00 48

REPORTING FRAUDHealthcare fraud costs the South African healthcare system billions of rands each year. Medical schemes are among the largest victims. This makes healthcare fraud one of the largest taxpayer rip-offsThe defi nition of fraud is the intentional misrepresentation of facts, which cause prejudice or potential prejudice of someoneWhat is Medical Scheme Fraud?• False Claims• Card Farming• Charging for services not covered by the scheme• Incorrect reporting of diagnosis or procedure• Changing service dates• Being admitted into hospital to claim back on hospital cash back plans where the patient is not sick• Corruption in the form of kickbacks and bribery

Anyone can contact Tip-offs AnonymousTrained operators respond to calls in English, Afrikaans, Xhosa, Zulu and Sotho 24 hours a dayAlternatively, you can use Email, FreePost or FreeFax within South AfricaTip-offs Anonymous will never reveal the identity of the caller and you don’t have to give your name

FreeCall: 0800 21 21 86FreeFax: 0800 00 77 88FreePost: KZN 138, Umhlanga Rocks, 4320

Email: [email protected]: www.tip-offs.com

CONTACT DETAILS

SERVICE PROVIDERThebe Ya Bophelo Administrators

• Referring Provider practice name and practice number• If accounts have been paid by the member, a receipt and provider account will be required. Claims will be reimbursed to you by means of a direct payment into your bank account. Due to industry fraud, cheques will not be issued, please provide Hosmed Medical Scheme with your bank details

No claim form is required. You can simply scan and e-mail your claims to [email protected]. Alternatively, you can post your account to:Hosmed Medical SchemeClaims DepartmentP.O. Box 16148DOORNFONTEIN, 2028

29

PHARMACY ADVISED THERAPY (PAT)

MEDICATION BENEFITS

• Applicable to schedule 1 and 2 over-the-counter medicines• Limited to a maximum of 1 script per 3 days• PAT limits per scheme option apply (claiming above the daily limit will incur co-payment) • PAT limit is a sublimit of the Acute limit

ACUTE MEDICATION

VALUE & PLUS• Subject to Medicine Formularies and Exclusion List• Acute limits per plan option apply

ACCESS & ESSENTIAL• Acute claims must be prescribed by a DSP GP doctor, otherwise the claim will reject (Essential Option)• Acute limits per plan option apply

CHRONIC MEDICATION

HOW TO REGISTERAn authorisation can be requested telephonically (preferred method),via fax or email. Mediscor ChroniLine may require additional information from your doctor or pharmacist. Based on the information provided your chronic condition will be registered and the appropriate medicines will be authorised

HOW TO AVOID CO-PAYMENTS• Use pharmacies that are in the Hosmed Preferred Provider Network• Make sure that you and your doctor know which medicines are listed on the chronic formulary specifi c to your option and chronic condition• Ask your pharmacist to dispense generic medicine that costs as much or less than the reference price for the prescribed formulary medicine

TYPES OF FORMULARIESOne of the measures used to manage fi nancial risk is medicine formularies. A formulary is a list of cost effective and accessible medicines that the scheme is prepared to make available to members for the treatment of a specifi c condition. The Hosmed formularies comply with the PMB treatment guidelines provided by the CMS. A number of alternatives will be available, from which your doctor can select one or more to treat your condition

DSP’sMediscor has established a preferred provider network (PPN) of compliant pharmacies committed to reduce member co-payments through accurate pricing, adherence to agreed dispensing fees and the promotion of generic substitution. The list of the preferred providers may be accessed via www.hosmed.co.zaPlease Note: Approved Chronic, PMB, HIV, Oncology and Organ Transplant medication may only be dispensed by providers in the Hosmed PPN

OTHER CHRONIC CONDITIONS

In addition to the Chronic Conditions covered under the Chronic Disease Management Programme (CDL), members will qualify for Other Chronic Conditions (per option), as listed below.

Claim queries: [email protected] applications & queries: [email protected]: www.mediscor.co.za

SERVICE PROVIDERMediscor

You will also be informed if you are liable to pay any co-payment/s, or if the medicines are not covered on you medical scheme option.Contact us on: Tel: 0860 00 00 48 option 3Fax: 0866 151 508 / 9Email: [email protected]

PLUS ACCESS & ESSENTIALVALUE

Attention Defi cit Hyperactivity Disorder (ADHD)Allergic RhinitisBenign Prostatic Hypertrophy (BPH)Cushing’s diseaseCystic fi brosisDepressionEndometriosisGastro-oesophageal refl ux disease (GORD)GoutHyperthyroidismHypoparathyroidismMenopause / Hormone replacement therapy (HRT)Motor Neuron diseaseMyasthenia gravisObsessive Compulsive DisorderOsteoarthritisOsteoporosisPaget’s diseasePituitary MicroadenomasPsoriasisPulmonary Interstitial fi brosisStroke (Cerebrovascular accident)

Attention Defi cit Hyperactivity Disorder (ADHD)Allergic RhinitisBenign Prostatic Hypertrophy (BPH)Cushing’s diseaseCystic fi brosisDepressionEndometriosis

GoutHyperthyroidismHypoparathyroidismMenopause / Hormone replacement therapy (HRT)

Myasthenia gravis

OsteoarthritisOsteoporosisPaget’s diseasePituitary MicroadenomasPsoriasis

Stroke (Cerebrovascular accident)

Benign Prostatic Hypertrophy (BPH)Cushing’s disease

Endometriosis

HyperthyroidismHypoparathyroidismMenopause / Hormone replacement therapy (HRT)

Myasthenia gravis

Paget’s disease

Stroke (Cerebrovascular accident)

30

FINDING A NETWORK PROVIDER

DENTISTRY

Contact the Hosmed Call Centre and select option 4 for dental enquiries and this will take you to Hosmed’s contracted dental provider Dental Risk Company (DRC). An agent there will gladly assist you in fi nding a provider in your areaOr if you have access to internet go to www.hosmed.co.za in the middle of the home page in orange is a block called “Provider network portals“ click on this and then click on the Dental Risk Company Logo. In the block shown below type the town, or suburb or city name you want to search and click on the search button and any provider in these areas will be displayed along with their contact details

HOW TO SUBMIT DENTAL CLAIMSDental providers and especially contracted providers will submit claims on your behalf. In the unlikely event that you need to pay an account and submit it you can either ask the accounts department of the provider to email it or you can email it to [email protected] or fax to 086 687 1285 please make sure your proof of payment is attached so that we can reimburse you directly and not the provider

HOW TO SUBMIT AUTHORISATIONS / MOTIVATIONS All contracted providers will submit this on your behalf. Should you not visit a contracted provider and you require specialised treatment or multiple fi llings the provider needs to provide you with a full quotation and this can be emailed to [email protected] or faxed to 086 687 1285. Please note we require full membership details on the quotation and an authorisation may take 2 to 3 working days. The time period is due to the fact that we may require further information from the provider but we will contact them and the member in such cases

WHICH ADVANCED DENTISTRY NEEDS TO BE AUTHORISED For dentistry it is important to note that any dentistry performed in theatre or any advanced dentistry or dentistry that is payable from your advanced benefi t must be pre-authorised prior to you receiving the treatment. This is in the member’s best interest as the member will also receive an authorisation letter stating what is covered and what is not so you will know upfront, what if any, is your fi nancial responsibility. Also keep in mind that extensive basic dentistry (more than 4 fi llings) needs to be authorised

PPN NETWORK PROVIDERS

OPTICAL BENEFIT

• The PPN network of providers accounts for over 97% of all registered optometrists in South Africa• To fi nd a PPN provider near you, logon to the PPN website www.ppn.co.za

WHY VISIT A PPN PROVIDER

Hosmed has partnered with Preferred Provider Negotiators (PPN) for the administration of all optical related claims and queries. PPN has 21 years of experience in the optical environment

• The PPN providers charge the PPN tariff pricing that is up to 72% lower than the industry standard pricing as charged by a NON PPN provider with no compromise on the quality of product• PPN providers stock a range of PPN frames that cost R150 enabling members of Hosmed to use their remaining frame benefi t towards lens enhancements, i.e. hard coating, tints, etc.

BENEFIT CONFIRMATIONS• Providers are able to confi rm benefi t via the PPN web based system• Members are able to view their benefi t entitlement via a secure login process on the PPN website www.ppn.co.za• Members and providers can also contact the PPN call centre 0861 103 529

CLAIMS SUBMISSIONS• Providers are able to submit claims via the PPN web based system called Optimum• Members and provider can submit paper claims to [email protected] or [email protected]

General Enquiries: [email protected] Pre-Authorisation: [email protected] Enquiries: [email protected]: www.dentalrisk.com

SERVICE PROVIDERDental Risk Company (DRC)

PPN Call Centre: 0861 103 529Claims submissions: [email protected] / [email protected] Claim queries: [email protected] Website: www.ppn.co.za

SERVICE PROVIDERPreferred Provider Networks

31

PPN WEBSITEThe PPN website has been designed to focus on the requirements of the member. It is fully mobile friendly and members can access it 24 hours a day. The PPN website provides:• A dashboard to members where they can log on, view their live benefi t entitlement, their claim history, print remittances and tax certifi cates• Members can also upload a photo and try on a PPN frame and or request to try it on at a specifi c practice• The optical benefi ts are also loaded per option and members can do a spectacle cost quotation online for their spectacles which will empower them more when they visit their optometrist

FRAUD CONTAINMENTPPN and Hosmed are committed to eradicating fraud within the optical claims environment. To this end, PPN has pioneered a number of provider fraud initiatives. Members can call the PPN fraud hotline on 0861 103 529 and report any fraudulent activities to which PPN will react and investigate immediately.

Types of fraud escalated include:• Replacing sunglasses for an optical claim• Service and materials not rendered• Card swopping

PREAUTHORISATION

HOSPITAL BENEFIT MANAGEMENT

In order for Hosmed to allocate benefi ts correctly and appropriately for a relevant health care service from your risk benefi ts you need to obtain a preauthorisation for the following: • A planned or elective admission to hospital for a surgical treatment (operation)• Expensive investigations done in hospital or out of hospital, e.g. MRI / CT scans, Radio-isotope studies, etc.• Outpatient Parenteral Antibiotic Therapy (OPAT) and / or expensive medications administered intravenously (given via a drip) on an outpatient basis• Emergency admission to hospital due to a medical or sickness condition or injuries sustained as a result of motor vehicle accident (MVA) or any other causes subject to the rules of the scheme

WHEN DO YOU HAVE TO APPLY FOR BENEFITS OR REQUEST PREAUTHORISATION• Immediately your doctor informs you of his / her intention to

admit you or your family member who is in your medical aid, to a hospital or to have a surgical procedure/s (operation) done in hospital or out of hospital

• Notify Hosmed at least 48 hours or 2 days before the planned admission

• In case of an emergency admission you must notify Hosmed within admission 24 hours by calling the Call Centre

HOW TO APPLY FOR PREAUTHORISATION?• You or your service provider can obtain preauthorisation by calling

the Preauthorisation Department at 0860 00 00 48• Alternatively, you can e-mail your request for preauthorisation to

[email protected]

WHAT INFORMATION DO YOU NEED BEFORE YOU CAN APPLY FOR OR REQUEST AUTHORISATION?You need to have the following information handy so as to facilitatequicker fi nalisation of your preauthorisation request:• Valid Hosmed membership number • Dependant code • Patient’s full names and date of birth• Date of admission and date of procedure (operation) • Name and practice number of the hospital or admission facility • Name and practice number of the treating doctor and telephone

number• Diagnosis and ICD 10 code (Reason for admission to hospital)• RPL Tariff code and CPT code (Name of surgical procedure or

operation to be performed in hospital)

WHAT HAPPENS IF YOU DO NOT OBTAIN PREAUTHORISATION?Failure to obtain preauthorisation as required by the rules of thescheme will result in the following:• A co-payment of R500 will apply for a hospital event on all plan

options• Benefi ts applicable on certain sub-limits may not be appropriately

allocated resulting in you being liable for any shortfall that may arise

WHAT DO YOU NEED TO DO AFTER BEING DISCHARGE FROM HOSPITAL?• Ensure that the hospital, your treating doctor and all other

associated service providers who treated you in hospital do submit their claims to Hosmed for payment according to the authorisation and the rules of the scheme

• Any claim that reaches Hosmed after 4 months from the date of service will be rendered stale and therefore not payable. You will effectively be liable for payment of such stale claims unless a valid reason can be provided for a late submission

OPTICAL BENEFIT continued

Hospital Pre-authorisation: [email protected] HIV / Aids Management: [email protected] Chronic Disease Management Programme: [email protected] Oncology Programme: [email protected] Bambino Maternity Programme: [email protected]: www.pha.co.za

SERVICE PROVIDERPrivate Healthcare Administrators (PHA)

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HIV / AIDS PROGRAMME

DISEASE MANAGEMENT PROGRAMMES

Hosmed HIV / AIDS Programme goes beyond registering a condition and allocating benefi ts. It is designed to address the needs of patients and families affected by HIV and AIDS

What does the programme entail?• Pre-testing and pre-treatment counselling and planning• Help in choosing the treatment that suits your needs• Education regarding the prevention of transmission as well as

healthcare and nutritional guidance• Monitoring of side effects and response to treatment to make sure

your medication is working for you• Encouragement of adherence and compliance with the

programme and medication• Liaison with your doctor when necessary and at your request• Medication benefi ts including anti-retroviral drugs• Consultation and diagnostic benefi ts• Prevention of mother to child transmission• Exposure to HIV positive blood e.g. sexual assault (Post Exposure

Prophylaxis)• Management of opportunistic infections

How to register onto the HIV / AIDS programme?• Call 0860 00 00 48 and select the HIV option (A professional nurse

will take your call and offer you the necessary assistance. The call is handled and treated with the highest level of confi dentiality)

• If you need to send an e-mail to any of the professional nurses who are dealing the with the programme, you can send it to [email protected] or alternatively send a fax to

086 604 0781

CDL CHRONIC DISEASE MANAGEMENT PROGRAMME This programme covers Chronic Disease List (CDL) conditions as per Prescribed Minimum Benefi t (PMB), such as Diabetes, Asthma, Hypertension, Cardiomyopathy, Addison’s disease, etc.

How to register on Disease Management programme?• Call 0860 00 00 48 and select the Disease Management option (A professional nurse will take your call and offer you the necessary help)• If you do have access to Hosmed Website www.hosmed.co.za,

you can download the Chronic Registration form and have it completed by your doctor and sent to the e-mail address

[email protected]

ONCOLOGY (CANCER) PROGRAMMEIt is important that prior to commencing active treatment for cancer, you are registered on the Oncology Disease Management Programme

Who needs to register?• Benefi ciaries diagnosed with a positive malignant histology that

requires some form of chemotherapy, radiotherapy, hormonal therapy and / or supportive therapy

How to register?• After you have been diagnosed with cancer your Oncologist must

fax a treatment plan and the histology results to the Scheme’s Oncology Department on 086 601 5474 or alternatively e-mail to [email protected]

BAMBINO MATERNITY PROGRAMME

HOW TO REGISTER?• Call Hosmed on 0860 00 00 48 (select maternity option)• You can also e-mail our in house Registered Midwife at [email protected]

WHAT INFORMATION DO YOU NEED TO HAVE WHEN CALLING TO REGISTER?• Your contact number or email address • Your GP, Gynaecologist or Registered midwife’s name surname as

well their practice numbers• Your expected date of delivery





33

GP AND DIAGNOSTIC BENEFIT MANAGEMENT FOR ACCESS AND ESSENTIAL PLANS

Prime Cure Call Centre: 0861 665 665 / 0860 00 00 48and press “0”to be transferred to Prime CureGeneral Enquiries: [email protected] submissions: [email protected] of GP: [email protected] Enquiries: [email protected]: www.primecure.co.za

SERVICE PROVIDERPrime Cure Health

Hosmed has contracted Prime Cure Health as an accredited Managed care Organisation to provide the General Practitioner Network, out of hospital pathology and basic radiology benefi ts on the Access and Essential options.Members who choose this option are restricted to obtaining their healthcare from a large national network of Prime Cure contracted providers. In order to ensure that all your claims are paid and you are aware of the benefi ts and rules of this scheme we have prepared an easy to use list of frequently asked questions and answers

WHAT IS A GP OR A DSP?GP is a General Practitioner or a Designated Service Provider (PrimeCure accredited Doctor)

WHERE DO I FIND THE MOST RECENTLY UPDATED LIST OF PRIME CURE SERVICE PROVIDERS?• Contact the Call Centre at 0861 665 665 or contact Hosmed on

0860 0048 and press “0” to be transferred to Prime Cure• Visit the website: www.primecure.co.za • Send a SMS to 33900. (You will receive a SMS back within a

minute, listing the providers name & contact number) SMS must say: ‘DOCTOR DURBAN’ (or relevant suburb / town)

HOW DO I NOMINATE A GENERAL PRACTITIONER? (ESSENTIAL OPTION)Members are to call the Prime Cure call centre on 0861 665 665 or fax 086 680 7124 or e-mail a form to [email protected] if they want to add, change or nominate General Practitioners. (“Change my GP Form” obtainable on www.primecure.co.za). Members should give notice of this impending change to take place 24 hours in advance of the event to ensure that the system is updated before the consultation takes place.Please note that each dependant should nominate their own General Practitioners• Member to provide the following information to the call centre: • Medical Scheme Number • Dependent code • Name of General Practitioner • Practice number (PR) of the General Practitioner (the PR number is important as we need to ensure you are allocated to the correct General Practitioner)

• If the nominated practitioner is not available or member is on holiday out of area on the day the member needs to consult with a GP, the member can phone Prime Cure for an authorization to consult with another Prime Cure DSP.

• Members / benefi ciaries on the Essential Option may nominate 3 General Practitioners

• Members / benefi ciaries on the Access Option do not need to nominate a General Practitioners but may only visit General Practitioners who are contracted to the Prime Cure Network

(DSP)

WHAT HAPPENS IF I VISIT A NON-CONTRACTED / DESIGNATED SERVICE PROVIDER (DSP) VISIT?Should the reason for a visit to a non-contracted provider not meet the defi nition of an emergency medical condition? • There is no cover on the Essential Option and a 25% co-payment of the agreed rate will be applied on the Access

Option• Authorisation to be obtained within 72 hours of the event.

Member will be required to pay for the consultation and all associated procedures and costs, and then submit the account to Prime Cure for reimbursement. (Please refer to REFUND PROCESS)

WHAT IF THE GENERAL PRACTITIONER OR DSP NEEDS TO PERFORM A BASIC PROCEDURE OR ADMINISTER AN INJECTION?As long as the medication prescribed, the procedure, the pathology and radiology tests are on the list of approved codes there will be no additional cost to the member. The member will be required to pay if they require radiology and / or pathology that are not on the approved list or if the required medication is not on the formulary

WHAT IS THE PRIME CURE PATHOLOGY PROCESS?These are available on the Access and Essential Options but are restricted to a formulary and must be referred by a contracted / nominated Prime Cure provider who will ensure that the tests are carried out at a contracted pathologist (Ampath, Pathcare and Lancet). The pathology formulary covers all basic pathology tests.

WHAT IS THE PRIME CURE RADIOLOGY PROCESS?There are 2 types of radiology tests: • Basic radiology (black and white x-rays and soft tissue ultra sounds) tests • Advanced radiology tests (MRI / PET and CT Scans) The basic radiology benefi t must be prescribed by a contracted / network doctor (DSP) and is on the list of approved codes. All black and white x-rays and soft tissue ultra sounds are covered according to the Option limits. You are also entitled to 2 sonar per pregnancy per annum if registered on the maternity programme. Only 2D scans are covered.The advanced radiology benefi t is limited to PMB’s and must form part of the treatment guidelines. Pre-authorisation is required by PHA and the Scheme would require a referral by a contracted Prime Cure provider.

34

HOW DO I GET REFUNDED?The member must submit the following documentation to Prime Cure:Full detailed account • Copy of proof of payment • Copy of member’s ID (ID of the person whose bank account the

refund must be paid into)• Full banking details [Member refunds form to be completed

(stamped by the bank, compulsory) and can be obtained from Prime Cure or on the Prime Cure website at www.primecure.co.za]• Type of account (If cheque account, please provide copy of

cancelled cheque)

All refund documents accounts must be posted to Prime Cure or emailed to [email protected]

Postal Address: Prime Cure REFUNDS DEPARTMENTPrivate Bag X13Rivonia2128

WHAT MUST I DO IF A PROVIDER / DOCTOR SENDS ME AN ACCOUNT?Before submitting a claim to Prime Cure, ensure that the following details refl ect on the account:• Principal member’s Initials and Surname• Patient details, name, surname and dependant code• Membership number• Name of the scheme and benefi t option e.g. Hosmed Access

option • Practice details of the treating provider (name and practice

number)• In the case of a Specialist, referring Prime Cure DSP name and

practice number and authorisation number• Date of service or treatment date• Claim code / tariff code and ICD10 code

All accounts must be posted to Prime Cure

Postal Address: Prime Cure CLAIMS DEPARTMENTPrivate Bag X13Rivonia2128

• Dedicated Intensive Care Units (equipped with specialised equipment) capable of facilitating inter-hospital transfers, ranging from adults through to neonatal ICU patients.

• Netcare 911’s Helicopter Emergency Medical Service (HEMS) currently operates two helicopter air ambulances in Gauteng, ensuring that an Emergency Care Practitioner-based helicopter service is available for immediate dispatch to life-threatening emergencies as a primary resource, 24 hours a day.

• The Netcare 911 jet air ambulance service operates primarily throughout South Africa, Africa and surrounding islands. All aircraft are fully equipped as mobile intensive care units, utilising only the latest in technology to ensure highly effective patient care.

Netcare 911 Medical Aid Scheme Cover provides medical scheme members with emergency medical service benefi ts while managing the medical care provided to members in the pre-hospital environment. This includes all associated transport costs, on behalf of the medical scheme.

The benefi ts include:• 24 hour access to the Netcare 911 Emergency Operations Centre

(including Nurse Line and telephonic advise)• Emergency call incident management and triage• Emergency response by road or air to scene of incident• Transfer from scene, to closest, most appropriate medical facility

for stabilisation and defi nitive care• Facilitation of medically justifi ed inter-facility transfers by road or

by air• Case management • Claims administration

Netcare 911 is one of the largest emergency service providers in South Africa. Since inception in 1998, Netcare 911 provides fully integrated and effi cient turnkey solutions to patients in crisis situations. Our core competence is contained in world-class emergency medical assistance, evacuation by road or air transportation, telephonic medical advisory services and a range of innovative products coupled with extensive management expertise thus mitigating risk on behalf of our clients.

In providing emergency management operations on par with international standards, Netcare 911 operates:

More than 100 operations in South Africa

• A fl eet of more than 200 emergency vehicles strategically placed throughout the nine provinces of South Africa.

• Rapid Response Vehicles (RRVs) equipped and crewed by Advanced Life Support Paramedics for immediate dispatch to any acute trauma or medical emergency. Ambulances are equipped for the transportation of ill and injured members of the public or clients, resourced by emergency care practitioners trained to the appropriate level of care specifi c to the patient’s condition at Basic, Intermediate or Advanced Life Support levels.


SERVICE PROVIDERNetcare 911

35

1. PRESCRIBED MINIMUM BENEFITS

EXCLUSIONS AND LIMITATIONS OF BENEFITS

2.6.4. 1087 - Sub-total reconstruction consisting of any two of the following:

2.6.5. Septum plasty, nasal osteotomy, nasal tip reconstruction

2.7. Mirena device Fund according to scheme protocol: 40 years of age. Not covered if used for contraception.

Cover for abnormal uterine bleeding. Insertion in rooms no co-payment applicable Insertion in theatre – co-payment R 800.00 even if done in

conjunction with another procedure Mirena device – cost from acute medicine benefi t 2.8. The Scheme reserves the right to impose and apply

exclusions and limits to the benefi ts that will be paid for medicines / procedures / interventions which have been accepted into the practice of clinical medicine through a process of health technology assessment / evaluation.

2.9. Benefi ts in respect of the cost of emergency medical treatment, as defi ned in the Medical Schemes Act, whilst abroad, are covered at 100% of Scheme Rates payable in RSA currency; Limited to the benefi t entitlement and PMB protocols that would have applied in South Africa.

2.10. High myopia – payable as per scheme protocols.

2.1. The Scheme may require a second opinion in respect of proposed treatment or medication which may result in a claim for benefi ts and for that purpose the relevant benefi ciary shall consult a dental or medical practitioner nominated by the Scheme and at the cost of the Scheme. The procedure to be followed in obtaining a second opinion is outlined in the relevant Scheme protocol (Protocol Regarding Requests For Second Opinions).

2.2. In cases where a specialist is consulted without the recommendation of a general practitioner, the benefi t allowed by the Scheme may, at its discretion, be limited to the amount that would have been paid to the general practitioner for the same service

2.3. Unless otherwise decided by the Scheme, benefi ts in respect of medicines obtained on a prescription are

limited to one month’s supply (or to the nearest unbroken pack) for every such prescription or repeat thereof.

2.4. If the Scheme or its managed healthcare organisation has evidence based funding guidelines or protocols in respect of covered services and supplies, benefi ciaries will only qualify for benefi ts in respect of those services

and supplies with reference to the available funding guidelines and protocols irrespective of clinical guidelines that are not consistent with the scheme protocols and benefi ts.

2.5. The Scheme reserves the right not to pay for any new technology. Coverage of new technology will be

assessed by the Scheme with due consideration given to:

2.5.1. medical necessity;

2.5.2. clinical evidence of its use in clinical medicine including outcome studies;

2.5.3. its cost-effectiveness;

2.5.4. its affordability;

2.5.5. its value relative to existing services or supplies;

2.5.6. its safety.

New technology is defi ned as any clinical intervention of a novel nature as well as those that the Scheme has not had previous experience with.

2.6. A 10% co-payment will be applied on the following procedure codes:

2.6.1. 1034 - Autogenous nasal bone transplant: Bone removal included

2.6.2. 1035 - Functional endoscopic sinus surgery: Unilateral

2.6.3. 1036 - Functional endoscopic sinus surgery: Bilateral

The Scheme will pay in full, without co-payment or use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefi ts as per Regulation 8 of the Act. Furthermore, where a protocol or a formulary drug preferred by the scheme has been ineffective or would cause harm to a benefi ciary, the scheme will fund the cost of the appropriate substitution treatment without a penalty to the benefi ciary as required by regulation 15H and 15I of the Act.

2. LIMITATIONS AND RESTRICTIONS OF BENEFITS

3. BENEFITS EXCLUDED General exclusions mentioned in this paragraph are not affected by any specifi c exclusion. Unless otherwise decided by the Scheme (and with the express exception of medicines or treatment approved and authorised in terms of any relevant managed healthcare programme), expenses incurred in connection with any of the following will not be paid by the Scheme:

3.1. all costs that exceed the annual or biennial maximum allowed for the particular category as set out in Annexure A, for the benefi ts to which the member is entitled in terms of the rules;

3.2. all costs for operations, medicines, treatments and procedures for cosmetic purposes or for personal reasons;

3.3. if, in the opinion of the medical advisor, the healthcare service in respect of which a claim is made, is not appropriate and necessary for any aspect of the management of the medical condition at an affordable level of service and cost;

3.4. all costs for treatment, if the effi cacy and safety of such treatment cannot be proved;

3.5. all costs for services rendered by: 3.5.1. persons not registered with a recognised

professional body constituted in terms of an Act of Parliament; or

3.5.2. any institution, nursing home or similar institution, except a state or provincial hospital, not registered in terms of any law;

3.6. abdominoplasties (including the repair of divarication of the abdominal muscles);

3.7. accommodation and services provided in a geriatric hospital, old age home, frail care facility or the like (unless specifi cally provided for in Annexure A);

3.8. acupuncture;3.9. anabolic steroids, immunostimulants (except for

immunoglobulins and growth hormones, which are subject to pre-authorisation by the relevant managed healthcare programme);

36

3.10. ante and postnatal exercises;3.11. appointments which a benefi ciary fails to keep;3.12. appliances, devices and procedures not scientifi cally

proven or appropriate; 3.13. arch supports including shoe inserts;3.14. aromatherapy;3.15. autopsies;3.16. ayurvedics;3.17. back rests and chair seats;3.18. bandages and dressings (except medicated dressings

subject to authorisation by the relevant managed healthcare programme);

3.19. beds and mattresses;3.20. bilateral gynaecomastia in benefi ciaries under the age of

18 years (in benefi ciaries over 18 years Scheme protocol will apply);

3.21. blepharoplasties; Unless there is documented evidence of visual impairment where the eyelid has covered or has encroached upon the pupil. Where this applies, benefi ts are limited to the affected eye only.

3.22. breast augmentation;3.23. breast reconstruction (unless necessitated by pre-

authorised surgical mastectomy, traumatic mastectomy or congenital unilateral absence of a breast which is subject to Scheme protocol);

3.24. breast reductions;3.25. Nasal surgery done by a plastic surgeon, nasal cautery

(procedure code 1069) if done with other intranasal procedures;

3.26. external cardiac assistive devices; unless part of a PMB protocol.

3.27. coloured or cosmetic effect contact lenses, and contact lens accessories and contact lens solutions;

3.28. contraception, (excluding tubal ligation and vasectomy), IUD’s for contraceptive purposes and contraceptive foams;

3.29. cosmetic preparations, emollients, moisturisers, medicated or otherwise, soaps, scrubs and other cleansers, sunscreen and sun tanning preparations, medicated shampoos and conditioners, not including coal tar products and the treatment of lice infestation, scabies and other microbial infections (subject to PMB regulations);

3.30. dental procedures or devices which are not regarded by the relevant managed healthcare programme as clinically essential or clinically desirable; and costs for:

3.30.1. anesthetics in respect of dental services: general anesthetics, conscious analgo-sedation

and hospitalisation for dental work except in the case of patients under the age of 7 years and symptomatic bony impaction of third molars;

3.30.2. labial frenectomies in respect of benefi ciaries under the age of 12 years;

3.30.3. orthodontic treatment over the age of 21 years; 3.30.4. periodontal plastic procedures for cosmetic

reasons; 3.30.5. use of high impact acrylic and precious metal in dentures or the cost of precious metal as an alternative to semi-precious or non-precious metal in dental prosthesis; 3.30.6. osseo-integrated tooth implants; genioplasty and

dental osteotomy

3.31. Oral hygiene instructions3.32. Dental implants, components and surgery associated with

dental implants3.33. Hospital admissions in adults based on fear and anxiety

alone3.34. Multiple admissions for extensive (3 or more teeth

requiring treatment) conservative dental treatment in children 7 years and younger. (1 admission every 24 months allowed.)

3.35. In-hospital Apisectomies, dentectomies and surgical tooth exposure for orthodontic reasons

3.36. Soft base to new dentures3.37. Diagnostic dentures3.38. Provisional crowns3.39. Laboratory cost of provisional and emergency crowns3.40. Metal, porcelain or Resin inlays except where such inlays

form part of a bridge3.41. Dental bleaching and porcelain veneers3.42. Resin bonding for restorations charged as a separate

procedure3.43. Crowns &bridge work, 4-surface fi llings and root canal

treatment on non-functional third molars (wisdom teeth) and Pontics on second molars

3.44. Fixed prosthodontics used to repair occlusal wear3.45. Periodontal fl ap surgery and tissue grafting; perio-chip3.46. Gingivectomy3.47. Metal base to full dentures, including the laboratory cost3.48. Lingual orthodontics and Orthodontic re-treatment3.49. Orthognathic (jaw correction) surgery and the related

hospital cost.3.50. Bone augmentations including materials and sinus lift

procedures3.51. Bone and other tissue regeneration procedures including

material cost3.52. Mouth guards; Snoring appliances; High impact acrylic;

Cost of Mineral Trioxide; Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments

3.53. Cost of gold, precious metal, semi-precious metal and platinum foil and invisible retainer material

3.54. Nutritional and tobacco counselling3.55. Caries susceptibility and microbiological tests3.56. Electrognathographic recordings and other such electronic

analyses3.57. Ozone therapy3.58. Polishing of restorations3.59. Pulp capping (direct and indirect)3.60. Root canal treatment and laboratory fabricated crowns on

primary teeth3.61. Fissure sealants on patients older than 16 years3.62. diagnostic kits, agents and appliances unless otherwise

stated except for diabetic accessories (subject to PMB regulations and Scheme protocols);

3.63. treatment of depression using sleep therapy;3.64. electric tooth brushes;3.65. treatment for erectile dysfunction and loss of libido;3.66. food and nutritional supplements including baby food and

special milk preparations;3.67. gender re-assignment treatment;

37

3.68. genioplasties;3.69. headaches: oral appliances and the ligation of temporal

artery and its branches for the treatment of headaches;3.70. hirsutism;3.71. holidays for recuperative purposes;3.72. humidifi ers;3.73. hyperbaric oxygen therapy subject to PMB regulations and

Scheme protocols;3.74. infertility treatment, subject to PMB regulations;3.75. ionizers and air purifi ers;3.76. iridology;3.77. surrogate pregnancy; including all services. 3.78. keloid surgery, except for burns and functional impairment

deemed by the Scheme to medically necessary;3.79. laxatives, subject to Scheme protocols;3.80. medical, surgical and orthopaedic appliances, devices

and products, including oxygen hire or purchase and attachments, subject to PMB regulations and Scheme protocols;

3.81. medication in respect of substance abuse treatment unless specifi cally authorised by the relevant managed healthcare programme, subject to PMB regulations;

3.82. medicines not included in a prescription from a medical practitioner or other healthcare professional who is legally entitled to prescribe such medicines (except for schedule 0,1 and 2 medicines supplied by a registered pharmacist);

3.83. medicine not approved by the Medicines Control Council or other statutory body empowered to approve / register medications;

3.84. MRI scans ordered by a general practitioner, subject to Scheme protocols;

3.85. obesity treatment;3.86. optical devices excluded by the relevant managed

healthcare programme;3.87. orthopedic shoes and boots, subject to Scheme protocols;3.88. osteopathy;3.89. otoplasties;3.90. pain relieving machines e.g. TENS, APS;3.91. medicines, household remedies and propriety preparations

and preparations not otherwise classifi ed;3.92. Positron Emission Tomography (PET) scans where

applicable; subject to ICON protocols and oncology registration

3.93. refractive surgery;3.94. excimer laser treatment;3.95. refl exology;3.96. revision of scars;3.97. rhinoplasties;

3.98. smoking cessation and anti-smoking preparations; 3.99. stethoscopes;3.100. sphygmomanometers / blood pressure monitors;3.101. sunglasses and repairs to spectacle frames;3.102. counselling, subject to prescribed minimum benefi ts;3.103. telephone consultations;3.104. tonics, evening primrose oil, fi sh liver oils, nutritional

supplements, multivitamin preparations and minerals except prenatal vitamins as approved by the Scheme’s pharmacy benefi t management programme;

3.105. topical preparations excluding topical steroid and acne preparations;

3.106. travelling expenses;3.107. uvulo-palatal pharyngoplasty (UPPP and LAUP);3.108. veterinary products;3.109. pharmacy service fees;3.110. facility fees;3.111. fentonplasty;3.112. Insulin pumps except for children 7 years or younger with

frequent documented events of hypo and hyperglycaemia3.113. Green laser prostatectomy3.114. services rendered during any waiting periods that are

imposed on the member or any dependent joining the Scheme;

3.115. all claims where ICD-10 codes are missing, invalid or incomplete will be rejected;

3.116. It is recorded that the relationship between the Scheme and its members shall at all times be deemed to be one of the utmost good faith.

3.117. Booking fees and birthing fees charged by providers for non-medical reasons.

3.118. Costs of diagnostic tests done in hospital which are not related to the reason for admission or for which admission is not clinically appropriate.

3.119. Allergy screening panels and / or desensitisation 3.120. Where the provider of service refuses to provide adequate

clinical motivation or supporting evidence of diagnosis the scheme reserves the right to decline funding

3.121. Medical admissions for treatment which could be provided in the rooms / home and there is no evidence of hospital based treatment being clinically necessary.

The member therefore acknowledges that, notwithstanding anything to the contrary, or not specifi cally set out in the rules or Annexures of the Scheme, the member is under a duty of care to disclose all and any information or matters to the Scheme, which may in any manner impact upon or affect a decision or discretion which vests in the Scheme, concerning such member or his claim

CALL CENTRE0860 00 00 48

www.hosmed.co.za

Disclaimer:Every effort has been made to ensure that this leafl et is an accurate explanation of the benefi ts offered by Hosmed Medical Scheme. Please note that this document does not replace the Rules of the Fund,which take precedence over any wording in this guide.

benefits and rates brochure 2016 · brochure 2016. a medical scheme that is in great health hosmed...

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