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CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd
PINNACLECompCare Wellness Medical Scheme
Information and Benefit Guide 2018
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The PINNACLE option is a new generation option that offers comprehensive cover, with unlimited hospital cover and superior day-to-day benefits. This option offers a savings account, flexible risk cover and extensive above-threshold benefits.
PINNACLECompCare Wellness Medical Scheme
Information and Benefit Guide 2018
DAY-TO-DAY BENEFITS ARE SUBJECT TO:• LEVEL 1: Personal Medical Savings Account (PMSA)• LEVEL 2: Annual Flexi Benefit (AFB)• LEVEL 3: Self-payment Gap (SPG)• LEVEL 4: Above Threshold Benefit (ATB)
BENEFITS PAID FROM RISK(Not subject to PMSA, AFB, SPG and ATB)• Wellness and Preventative Benefits• Unlimited GP visits and Conservative Dentistry
(after limits reached)• Ambulance Services, Netcare911
HOSPITAL BENEFIT• Unlimited cover, including private wards, 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, including private wards. 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 admission, failing which a co-payment of R500 per admission will apply.
CompCare Pre-authorisation / 0860 111 090
A co-payment of R1 500 is payable on specified elective procedures (excluding PMBs*) done in a hospital or specified 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 exclusion of dentist accounts relating to hospital admissions are unlimited and paid at 200% of the Scheme rate.
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 reference pricing.
Biological agents and specialised medicines are limited to R260 000 per family. 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 R55 250 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. The first R2 500 of the specialised radiology account will be paid from the member’s Personal Medical Savings Account. 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 Pre-authorisation / 0860 111 090
Mental health benefitsPsychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health institution.
Non-Psychiatric hospital admissions are limited to R3 683 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 procedures• 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 R6 570 per eye
IN-HOSPITAL BENEFITS
DAY-TO-DAY BENEFITSLEVEL 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 R1 110 R864 R306
AFB R3 510 R2 732 R972AnnualSavings R13 320 R10 368 R3 672
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 LEVEL 4Self-Payment Gap (SPG)
When you run out of PMSA and AFB, you will have to pay for some healthcare expenses from your pocket before you reach your Annual Threshold. This gap in cover is called a Self-payment Gap (SPG).
While you are in your SPG you must still send claims to us so that we know when to start paying from your Above Threshold Benefit (ATB).
The Above Threshold Benefit (ATB)
Once your accumulated claims submitted reach the Annual Threshold, you will have access to the Above Threshold Benefit (ATB).
Values of the SPG and Annual Threshold 2018 ATB limits 2018
P A C Per beneficiary R9 150
Annual Threshold R18 830 R14 591 R5 128
Per member family R18 310Self-payment
gap R2 000 R1 490 R484
The PINNACLE option provides cover for 72 chronic conditions. These include 26 conditions from the Chronic Disease List (CDL) as published in the Medical Scheme Act and 46 chronic conditions not listed as CDLs.
For a list of chronic conditions covered on the Pinnacle option, please refer to www.compcarewellness.co.za.
Medicine benefits for CDL chronic conditions (PMBs) are unlimited with no levy or co-payment if the medicine forms part of the Scheme’s formulary and the price of the medicine is equal or less than the reference price for the product.
Non-CDL chronic medicines are initially paid from the member’s available PMSA, AFB and SPG for registered conditions and limited to R11 680 per beneficiary and R17 500 per family.
Members also have access to an Above Threshold Benefit of R4 400 per family.
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 Pre-authorisation / 0860 111 090
CHRONIC CONDITIONS
DAY-TO-DAY BENEFITS SUBJECT TO PMSA, AFB, SPG AND ATB
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
Above Threshold Benefits and sub-limits
(All sub-limits are subject to the overall ATB limits)
GP consultations, procedures and materials Unlimited, not subject to ATB limits
Specialist consultations, procedures and materials
Paid at 200% of the Scheme rate
A referral from a GP is required before seeking treatment from a specialist except for services provided by an ophthalmologist, gynaecologist, oncologist or 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 authorised
R4 400 per family
Acute medicines Prescription medicines - Schedule 3 and higher
A 25% co-payment is applicable on non-generic products. Reference Pricing applies to medicines where a generic product is available and might result in a co-payment
R3 650 per family
Over the counter medicine (OTC) and homeopathic medicine
R200 per event, R970 per beneficiary per
annum and R1 380 per family per annum
No above threshold benefit
Basic radiology Including black and white X-rays and ultrasound
R4 395. Combined limit with Pathology
Specialised radiology MRI, CT, High resolution CT and PET scans
The first R2 500 is payable from PMSA,
AFB and SPG with accumulation to threshold, except
for PMBs, thereafter unlimited from in-
hospital benefit
Pathology R4 395. Combined limit with Radiology
DentistryConservative and restorative
Unlimited, not subject to ATB limits
Specialised dentistry Dentures, crowns, bridgework, metal fillings and inlays, orthodontics, prosthodontics, periodontics, Osseo integrated implants including the cost of the appliances and prosthesis, maxillofacial and oral surgery
R16 840 per beneficiary No above threshold benefit
OptometryConsultations
Two tests per beneficiary per annum
No above threshold benefit
OptometryLenses, contact lenses and disposable lenses
R4 395 per beneficiary per annum
No above threshold benefit
OptometryFrames
R2 230 per beneficiary per annum, included in
lenses limit
No above threshold benefit
Auxiliary servicesIncluding audiologist, chiropractors, dieticians, homeopaths (consultations), naturopaths (consultations), speech and occupational therapists, chiropody/ podiatry, social workers, physiotherapy and biokineticists
R7 300 per family
R2 890 for physiotherapy and biokineticists only,
subject to benefits within the overall Auxiliary
sub-limit
Mental Health - Clinical psychologists R4 810 per family No above threshold benefit
Mental Health - Psychiatry R16 050 per family No above threshold benefit
Oxygen home ventilation No above threshold benefit
Private nursing homes 60 days No above threshold benefit
Ante-natal classes12 ante-natal classes, limited to R1 245 per
pregnancy
No above threshold benefit
Surgical and medical appliancesWheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators
EmergenciesAmbulance services - Emergency roadside assistance and ambulance transportation.
NETCARE / 082 911
In the case of non-emergency cases, authorisation must be obtained from Netcare911 at the time of transportation or within 24 hours thereof, failing which will result in a 25% co-payment.
Hospital emergency room / Casualty emergency visits not requiring admission are paid from and limited to the member’s PMSA and AFB.
Hospital emergency room / Casualty emergency visits resulting in a hospital admission will be paid from the in-hospital benefit.
Hospital emergency room / Casualty emergency visits as a result of physical injury caused by an external force will be paid in full.
Child emergency benefit - If the PMSA and AFB are depleted members will have access to one additional visit to an emergency facility per child younger than 6 years per annum. Limited to R1 050 per event.
Psychosocial counselling benefitUnlimited telephonic counselling sessions with a psychologist or social worker with the option of referral for one-on-one sessions with qualified psychologists or social workers to a maximum of 3 sessions per beneficiary per annum.
Benefit relates to psychosocial counselling related to substance abuse, emotional stress, major life events e.g. birth, accidents and death, separation and loss, health care concerns, family or personal relationship issues, concerns about eldercare, childcare, parenting issues, family violence, harassment, work-related stress, balancing work and family, etc.
Services provided by DSP Network of psychologists and social workers
CompCare Pre-authorisation / 0800 390 003
DAY-TO-DAY BENEFITS PAID FROM RISK
All wellness and preventative benefits are paid from risk and will not impact your savings account PMSA or AFB unless otherwise specified.
WELLNESS AND PREVENTATIVE BENEFITS
Wellness Checks• One GP wellness consultation per beneficiary per annum.• Blood pressure, blood sugar, cholesterol, BMI and waist circumference
– one measurement per beneficiary over the age of 18 years, limited to R180 per event.
• Mammograms - one test per female beneficiary over the age of 35 every second year.
• Pap smears - one test per female over the age of 18 per annum.• PSA (Prostate Specific Antigen) - one test per male beneficiary over the
age of 40 per annum.• Dental - one check-up per beneficiary per annum.• Glaucoma test - one test per beneficiary per annum.• Baby wellness visits - two visits per annum for children between
4 weeks and 18 months.• Hearing and eye tests - one hearing and eye test for pre-school children
aged 5 to 6 years.• School Readiness Assessment (examination for admission to
educational institution only tariff codes 86211 and 86290 qualify).• Career Guidance (only tariff code 86211 and 86290 qualify).
Vaccinations and immunisations• Flu vaccinations - one dose per beneficiary per annum.• HPV (cervical cancer) vaccine - one course (3 doses per registered
schedule) per female beneficiary between ages 12 and 18 years.• Adult pneumococcal vaccine (Pneumonia) as required.• Childhood pneumococcal vaccine as required.• Tetanus vaccine - one injection when required.• Childhood immunisations as recommended by the Department of
Health up to 12 years.
• Fitness assessment and exercise prescription – members have access to the Universal Network of biokineticists for an annual fitness assessment, exercise prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply.
• Fitness assessment for pregnant women – members have access to one fitness assessment per pregnancy. Pre-authorisation is required and protocols apply.
• Nutritional assessment and healthy eating plan – members have access to the Universal Network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply.
• Nutritional assessment for pregnant women – once per pregnancy.
Other preventative benefits• Oral contraceptives - limited to R126 per beneficiary per month.
Formulary and Reference Pricing applies.• Malaria Prophylaxis (prevention medicine) as required.
PREVENTATIVE BENEFITS
HEALTHY LIFESTYLE BENEFITS
Contributions Effective from 1 January 2018
Monthly Principal Member
Adult Dependant
Child Dependant
Risk R4 740 R3 690 R1 314
Savings R1 110 R864 R306
Total R5 850 R4 554 R1 620
Annual Benefit Amounts for 2018Principal Member
Adult Dependant
Child Dependant
Annual Savings R13 320 R10 368 R3 672
Annual Threshold (incl AFB) R18 830 R14 591 R5 128
Annual Self Payment Gap R2 000 R1 490 R484
COMPCARE WELLNESS MEDICAL SCHEME
CONTACT USCompCare Wellness Medical SchemeUniversal Place, 19 Tambach Road,Sunninghill Park, SandtonPO Box 1411, Rivonia, 2128
Tel: 0861 222 777 / Fax: 0866 450 991E-mail: [email protected]: www.compcarewellness.co.za
Contact details for complaints escalated to the Council for Medical SchemesTel: 0861 123 267E-mail: [email protected]: www.medicalschemes.com
GLOSSARYA – Adult DependantAFB – Annual Flexi BenefitATB – Above Threshold BenefitC – Child DependantCDL – Chronic Disease ListDSP – Designated Service ProviderOTC – Over the Counter MedicineP – Principal MemberPMB – Prescribed Minimum BenefitsPMF – Per Member FamilyPMSA – Personal Medical Savings AccountSPG – Self Payment GapTTO – To Take Out (Medicine taken on discharge from hospital)
* A child dependant is a dependant who is under the age of 21 years or a full time student up to the age of 27 years. An adult dependant is a dependant who is 21 years or older. The above rates are only applicable to the main member and a maximum of three child dependants.
This brochure is a summary of the benefits of CompCare Wellness Medical Scheme. All information relating to the 2018 CompCare Wellness Medical Scheme benefits and contributions are subject to formal approval by the Council for Medical Schemes. On joining the Scheme, all members will receive a detailed member brochure, as approved. The final registered Rules of the Scheme will apply.
CompCare Wellness Medical Schemes is administered by Universal Healthcare Administrators (Pty) Ltd.
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VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS /
