BESTmed Medical Scheme Product Range

1
BESTmed Medical SchemeProduct Range
2
Agenda

• Product Range
• Millennium Comprehensive
• Millennium Standard
• Bonus Plus
• Blueprint
• Conclusion Comparison

3

• PRODUCT RANGE

4
Product Range

• Millennium Comprehensive
• Millennium Standard
• Bonus Plus
• Blueprint

5
ABOVE THRESHOLD BENEFITS
Self payment gap
Day to Day expenses Savings Account (20 of total
contributions)
Services while hospitalized and Formulary
medicine (57 conditions) HIGH RISK BENEFITS
6
High Risk Benefits

• Hospital services
• 100 of contracted fees
• Unlimited No co-payment
• Services included in Oncology and HIV/Aids
  programs
• Chronic medicine 85 of cost for medicine for
  57 specified conditions, limited to
• M0 R5 500 M2 R 10 000 M1 R9 000 M3 R
  11 000
• Surgical dentistry
• Mental health clinics
• Advance Radiology (MRI, CT Scan)
• Prosthesis surgically implanted R30 000 and not
  surgically implanted R20 000 (60 months)
• Ambulance service Netcare 911

7
Individual Savings Account

• Pays for out-of-hospital medical expenses and
  those not covered under High Risk Benefits
• Distinguish between threshold contributing and
  non threshold contributing expenses
• Pay according to cost (only NHRPL/BESTmed tariff
  amount add towards threshold)
• Total amount available in the beginning of the
  year
• Examples of services paid from available funds in
  IMSA
• GP consultations Specialist consultations
• Acute medicine Over the counter medicine (non
  TC)
• Dental services Optical services

8
Above Threshold Benefits

• Threshold amounts are determined by BESTmed at
  the beginning of each year
• Threshold is the required amount which should be
  paid from IMSA and/or by member himself before
  access to the Above Threshold Benefits (ATB) are
  granted.
• R5 000 per adult and R1000 per child
• Above Threshold Benefits are services usually
  being paid from IMSA but after threshold was
  reached those services will be paid as ATB and
  not from the IMSA
• Available ATB Annual ATB paid from IMSA
• Safety net for those families with higher health
  care needs

9
Above Threshold Benefits

• Acute medicine
• Range from R5780 to R11 500
• Biological medicine
• R100 000 per beneficiary per year
• Pathology and Radiology
• from R6830 to R9240.
• Conservative dentistry
• Unlimited
• Advanced dentistry
• from R4830 to R8400
• GP and specialist consultations
• from R2140 to R3930

10
Member Fees
Threshold R5000 per adult R1000 per child
11
SAVINGS ACCOUNT (15 of contributions)
SUPPLEMENTARY BENEFITS
Services while hospitalized and Formulary
medicine (57 conditions) HIGH RISK BENEFITS
12
High Risk Benefits

• Hospital services
• 100 of contracted fees
• Unlimited No co-payment
• Chronic medicine 85 of cost for medicine for
  57 specified conditions, limited to
• M0 R2 500 M1 R 2800 M2 R3 000 M3 R 3
  200
• Surgical dentistry
• Mental health clinics
• Advance Radiology (MRI, CT Scan)
• Prosthesis surgically implanted R30 000 and not
  surgically implanted R20 000 (60 months)
• Ambulance service Netcare 911

13
Supplementary Benefits

• OPTICAL SERVICES
• 100 of agreed tariff and subject to limits
• Per beneficiary per 24 month
• one test and one pair of spectacles and lenses
  or contact lenses
• PREVENTATIVE DENTISTRY
• 100 of BESTmed tariffs structure
• Subject to limits and requirements set by
  BESTmed.
• RADIOLOGY
• 100 of BESTmed tariffs for one ultrasound sonar
  per pregnancy per financial year

14
Savings Account

• Pays for out-of-hospital medical expenses and
  those not covered by High Risk Benefits
• All payments are subject to available funds in
  the Savings Account
• Paid according to cost
• Total amount available in January

15
Member Fees
Annual Income ltR54 000
16
Member Fees
Annual Income gt R54 000
17
(No Transcript)
18
Benefit Structure

• DAY TO DAY BENEFITS
• Cover for services received not while
  hospitalized
• Limits -
• Benefit type specific limit
• Overall Annual limit of R12 000 for family and R6
  000 per single member
• IMSA
• First portion of all claims paid are paid with
  the monthly contribution that is made towards the
  IMSA before paying as Day-to-Day
• If claimed amount is less than IMSA portion it
  will be carried over to the Bonus Account
• BONUS ACCOUNT
• Unutilised IMSA payments can be use to pay
  claims after limits were reached or when
  day-to-day benefits are depleted.
• HIGH RISK BENEFITS
• Hospital treatment unlimited, 100 of agreed
  tariffs
• Chronic medicine (annual limits applicable)

19
Important

• You do not have access to the total amount in
  your Savings Account, only to the amount that you
  are monthly contributing.
• You have access to Day-to-day benefits subject to
  the following
• PER YEAR
• R12 000 family or R6 000 for individual member
• PER SERVICE TYPE
• The amount indicated under each specific benefit.

20
High Risk Benefits

• Hospital services
• 100 of contracted fees for hospital expenses
• No overall limit No co-payment
• Oncology treatment
• R30 000 per year per beneficiary
• Surgical dentistry
• R6720 per year per family
• Mental health clinics
• 21 days per beneficiary per year
• Advance Radiology (MRI, CT Scan)
• 100 in hospital (pre authorisation required)
• Prosthesis
• surgically implanted R30 000
• not surgically implanted R20 000 (60 months)
• Ambulance service
• Netcare 911
• Alternatives to hospitalisation (step down
  facilities)
• R15 000 per family per year

21
High Risk Benefits

• Chronic medicine
• 85 of contracted fee (57 conditions),
• limited to Mediscor Medicine Price
• Generic medicine (formulary)
• Single member R 5 000 per year
• Family R10 000 per year
• Generic medicine only

22
Day-to-Day benefits

• Advanced Radiology
• MRI, CT Scans R5000 per family per year
• Medical aids, apparatus and appliances
• R5000 per family per financial year
• Dentistry
• combined conservative and specialized dentistry.
• Single member R2 000 Family R4000
• GP Specialist visits as well as acute medicine
• Single member R2 000 Family R4 000
• Optical benefits
• Single member R1000 Family R 2000 (per 24
  months)
• Pathology Radiology out of hospital
• Single member R1500 and Family R3 000

23
Savings Account

• 22 of total contribution
• Claims will be paid from monthly contribution
  first then when this amount is depleted
  claims will be paid from the Day-to-Day benefits.
• Unused amounts will be carried over to the Bonus
  Account during the fifth month.
• Do not have access to total amount in Savings in
  advance in the beginning of the year only
  access to the monthly contributed amount.

24
Bonus Account

• Vested Savings Account funds
• Can be used to pay claims after limits were
  reached or when service specific benefit amounts
  were reached.
• At end of year the balance in the Bonus Account
  will earn interest and it will be paid to the
  following years savings account.

25
Member Fees
Additional adult or special dependants R800 per
dependant
26
SPECIALIST CONSULTATIONS AND OUT-OF-NETWORK
CONSULTATIONS
27
Primary Health Care
28
Where?
Providers contracted with Primecure or Carecross
Member chooses network on registration Get
list of contracted providers from
www.primecure.co.za or www.carecross.co.za or
phone Client Services (012-3399800)
29
Important

• Unlimited medicine, GP consultations, pathology
  and x-trays should it be obtained from contracted
  providers and should the contracted GP referred
  the patient.
• Treatment protocol applies
• Spectacles 24 months (sight must be worse than
  a certain strength)

30
Specialists

• 3 Specialist visits per family per year
• R780 per consultation (BESTmed tariffs apply)
• Pre authorisation from BESTmed before consulting
  specialist
• Must be referred by contracted GP

31
Out of network consultations

• 2 out-of-network consultations per family per
  year
• R400 per visit (BESTmed tariffs apply)
• Inform BESTmed within 24 hours after consultation
• Must be when contracted providers were not
  available such as during weekends or after hours

32
Hospital treatment

• No Annual limit for all services received while
  hospitalised.
• Must be referred by Primary Care Provider
• Must be pre-authorized by BESTmed
• Only services as pre-authorized will be covered
• Private hospital except in case of treatment for
  the following conditions or procedures - are only
  covered in public or provincial hospitals
• Treatment of chemical or substance abuse
• Cancer
•       Haemodialysis
• Heart Pacemakers

33
Member Fees
34
CONCLUSION
35
Criteria to compare options

• Chronic Medicine cover
• Amount Formulary
• Hospital cover Disease Management Programs
• Cover for out-of-hospital services
• Freedom of choice with regard to service providers

36
Criteria

• CHRONIC MEDICINE
• Mill Comprehensive 57 conditions (R11 000)
• Bonus Plus 57 conditions (R10 000) Generic
  medicine only MPL apply
• Mill Standard 57 conditions (R3 200)
• Blueprint As provided by Primecure Carecross
• HOSPITAL COVER DISEASE MANAGEMENT PROGRAMS
• Hospital cover No annual limit all options
• Blueprint certain
  treatment - public facilities
• Disease management Oncology programme limited
  to
• Millennium Comprehensive

37

• OUT-OF-HOSPITAL TREATMENT
• More out-of-hospital cover
• Blueprint (primary health care)
• Bonus Plus
• Mill Comprehensive
• Less out-of-hospital cover (add ABSA card)
• Mill Standard (Savings 15 of contributions)
• PREFERRED SERVICE PROVIDERS
• Blueprint Primary health care services limited
  to Primecure or Carecross network providers