CompCare Wellness Medical Scheme .CompCare Wellness Medical Scheme Information and Benefit Guide

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  • CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd

    SYMMETRYCompCare Wellness Medical Scheme

    Information and Benefit Guide 2018

    / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION /

    VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING /

  • CompCare Wellness Medical Scheme

    Information and Benefit Guide 2018

    The SYMMETRY option is a new generation option that offers exceptional cover, with unlimited hospital cover and superior day-to-day benefits consisting of a savings account and flexible risk cover. Additional cover for specified services are available once the savings account and flexi risk benefits are exhausted.

    SYMMETRY

  • DAY-TO-DAY BENEFITS ARE SUBJECT TO: LEVEL 1: Personal Medical Savings Account (PMSA) LEVEL 2: Annual Flexi Benefit (AFB)

    BENEFITS PAID FROM RISK (not subject to PMSA and AFB) Wellness and Preventative Care Benefits Unlimited GP visits (after limits reached) Ambulance Services, Netcare911

    HOSPITAL BENEFIT Unlimited cover for in-hospital and hospital-

    related services

    ACHIEVE YOUR OPTIMAL HEALTHWITH COMPCARE WELLNESS MEDICAL SCHEME

  • HospitalisationMembers have full access to all private hospitals throughout South Africa. All hospital accounts are paid in full at a rate agreed between the Scheme and the individual hospital groups.

    In the case of elective admissions, authorisation must be obtained at least 48 hours before a beneficiary is admitted to a hospital or day clinic failing which a co-payment of R2 000 per admission will apply. Late authorisations will require a R1 000 co-payment.

    In the event of a medical emergency the Scheme must be notified within one working day following the admission, failing which a co-payment of R500 per admission will apply.

    CompCare Chronic Registrations / 0860 111 900

    Co-payments are payable on specified elective procedures (excluding PMBs*) done in a hospital or a day facility.

    *PMB = Prescribed Minimum Benefit as defined in the Medical Schemes Act No 131 of 1998.

    For the co-payment schedule, please refer to www.compcarewellness.co.za.

    Hospital related accountsUnless otherwise indicated in-hospital related benefits are unlimited and accounts are paid at 100% of the Scheme rate. These include but are not limited to: General Practitioner visits Radiology Pathology Surgical procedures Blood transfusions Auxiliary services (i.e. physiotherapy) Sports injuries

    Specialist accounts with the exception of dental accounts relating to hospital admissions are unlimited and paid at 100% of the Scheme rate.

    Physiotherapy in hospital is limited to R7 360 PMF

    While in hospital medicine is unlimited, medicine prescribed on discharge (Medicines TTO) is limited to a supply of seven days. Non-PMB medicine is subject to the reference pricing.

    Biological agents and specialised medicines are limited to R130 500 per family. A 25% co-payment is applicable. These medicines can only be obtained if pre-authorised.

    Surgical Prostheses (e.g. artificial joints, stents, artificial limbs) and electronic/nuclear devices (e.g. pacemaker, defibrillators, nerve stimulators and cochlear implants) are limited to an overall limit of R41 440 per family. Sub-limits per sub-category apply. Sub-limits can be viewed on the CompCare website or obtained from the CompCare Call Centre.

    Specialised radiology includes MRI, CT scans and high resolution PET scans and is limited to R26 310 per family per annum. The first R1 500 of the specialised radiology account will be paid from the members Personal Medical Savings. Pre-authorisation is required for all MRI and CT Scans. High resolution CT Scans/PET Scans are subject to special medical motivation and also requires pre-authorisation. There is no benefit for unauthorised scans, except for PMBs. No benefits are available for screening or investigative purposes.

    Maternity benefitsExpecting mothers have access to 12 Antenatal consultations with a GP or specialist which are paid from risk (not from the Day-to-Day benefits).

    Confinements are subject to clinical protocols. Ultrasound pregnancy scans are limited to two 2D scans.

    Expecting mothers are encouraged to register on the maternity programme and receive a baby bag. Please also remember to obtain pre-authorisation for the confinement.

    CompCare Chronic Registrations / 0860 111 900

    Mental health benefitsPsychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health institution.

    Non-Psychiatric hospital admissions are limited to R2 630 per family.

    Alcoholism, drug dependence and narcotism hospitalisations are only authorised in the case of PMB conditions.

    Pre-authorisation is required and protocols apply.

    Hospitalisation relating to the following conditions and procedures are covered in full for PMB conditions only:

    Organ and tissue transplants Renal dialysis Plasmapheresis

    Pre-authorisation is required and protocols apply.

    The following alternatives to hospitalisation are available subject to pre-authorisation and protocols and unlimited unless otherwise specified:

    Step-down nursing facilities, hospice and rehabilitation Terminal care (Imminent death, regardless of diagnosis) Out of hospital surgical prosthesis Oncology, including chemotherapy and radiotherapy (See limit

    on biological agents and specialised medicines) Wound care in lieu of hospitalisation Excimer Laser Refractive Surgery limited to R4 420 per eye

    IN-HOSPITAL BENEFITS

  • LEVEL 1 LEVEL 2

    Personal Medical Savings Account (PMSA)We pay your day-to-day medical expenses from the available funds in your PMSA. Any unused funds will be carried over to the next year.

    Annual Flexi Benefit (AFB)When you run out of PMSA, you will have access to an Annual Flexi Benefit. The AFB is a risk benefit.

    PMSA values for 2018 AFB Values for 2018

    P A C P A C

    Monthly Savings R348 R270 R96

    AFB R4 176 R3 240 R1 152AnnualSavings R4 176 R3 240 R1 152

    The PMSA will be pro-rated if you join during the course of the year. PMB related benefits will be paid for from your AFB risk benefit and not from your PMSA.

    The AFB will be pro-rated if you join during the course of the year.

    LEVEL 3

    Additional CoverWhen you run out of PMSA and AFB, we will pay for specified healthcare expenses from risk.

    These include:

    GP visits (consultations only)

    DAY-TO-DAY BENEFITS

    The SYMMETRY option provides cover for 46 chronic conditions. These include 26 conditions from the Chronic Disease List (CDL) as published in the Medical Scheme Act and 20 chronic conditions not listed as CDLs.

    For a list of chronic conditions covered in the Symmetry option, please refer to www.compcarewellness.co.za.

    CDL and Non-CDL chronic conditions are subject to the AFB and a sub-limit of R4 315 per beneficiary and R6 480 per family is applicable. Once the benefit is depleted, CDL medicines are unlimited.

    Medicine benefits for CDL chronic conditions (PMBs) are unlimited and initially paid from the members available AFB (sub-limits applicable please see above) with no levy or co-payment if the medicine forms part of the Schemes formulary and the price of the medicine is equal or less than the reference price for the product. Thereafter medicines are unlimited.

    Non-CDL chronic medicines are paid from the members available PMSA and AFB (sub-limits are applicable please see above).

    Members are required to register for all CDL and non-CDL applicable covered chronic conditions.

    Prior to registration on the chronic programme, only the first prescription will be paid from the acute medicine limit. Formularies and reference pricing applies. A 25% co-payment is payable for the voluntary use of non-formulary medicine.

    CompCare Chronic Registrations / 0860 111 900

    CHRONIC CONDITIONS

  • All benefits are paid at 100% of the Scheme rate unless otherwise specified.

    Benefits paid from available funds in PMSA and AFB where

    no sub-limits are applicable

    Sub-limits while PMSA and AFB funds are available

    GP consultations, procedures and materials

    Specialist consultations, procedures and materials

    Paid at 100% of the Scheme rate

    A referral from a GP is required before seeking treatment from a specialist, failure which will result in a 30% co-payment. No referral required for services provided by an ophthalmologist, gynaecologist, oncologists or a urologist (for beneficiaries over the age of 40) and a paediatrician in respect of children under the age of 2 years or where multiple visits to a specialist are authorisedAcute medicines Prescription medicines - schedule 3 and higher

    A 25% co-payment is applicable on non-generic products. MMAP (Maximum Medical Aid Price) applies to medicines where a generic product is available and might result in a co-payments.

    Over the counter medicine (OTC) and homeopathic medicineR170 per event, R680 per

    beneficiary per annum andR1 105 per family per annum

    Basic radiology Including black and white X-rays and ultrasound

    Specialised radiology MRI, CT, high resolution CT and PET scans

    The first R1 500 is payable from PMSA and AFB,

    combined with and limited to R26 310 from in-hospital

    benefit

    Pathology

    Subject to PMSA and AFB, combined with and limited to

    R31 575 from in-hospital benefit

    DentistryConservative and restorativeSpecialised dentistry Dentures, crowns, bridgework, metal fillings and inlays, orthodontics, prosthodontics, periodontics, Osseo integrated implants including the cost of the appliances a