2 0 1 7 PRODUCT UPDATE CARING AFFORDABLE SIMPLE Over 3 - - PowerPoint PPT Presentation

2 0 1 7

PRODUCT UPDATE

CARING AFFORDABLE

SIMPLE

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Over 3 decades of History

·

Over R1 billion

·

47% Solvency

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A+ Global Credit Rating

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Over 121 954 lives covered

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33 Average age ratio

0% 1% 2% 3% 4% 5% 6% 7% 8% J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D 2014 2015 2016 Headline CPI inflation (y/y) Bottom range Upper range

Budget Assumptions

CPI 6.5% Hospital Tariffs 6.5% (CPI + 1%) Medicines (SEP) 8.6% (5.7% + 2.9% gazetted increases) Reference price list 6.5% Utilization (plus ageing as well as supplier induced demand) 2.5% Investment return 6.5%

AVERAGE INCREASE

8.9%

INCREASES FOR 2017

PRODUCT HIGHLIGHTS BASIC RADIOLOGY AND PATHOLOGY

Basic radiology and pathology Introduction of a sub-limit on basic radiology and pathology out of hospital. Dentistry Introduction of the following limits for dentistry.  Primary Care - A limit of R2 800 per family on conservative dentistry.  Affordable Care - A limit of R3 200 per family on conservative dentistry.  Full Benefit - A limit of R3 600 per family on conservative dentistry and R3 600 per family on specialised dentistry (excluding orthodontics). Benefit for plastic dentures covered over a 4 year period, regardless of whether full or partial dentures are provided. Benefit for implants be increased by more than inflation, from R2 350 to R3 500 in 2017. DENTISTRY

Primary Care: M:R1 000 and M+:R1 900 Affordable Care: M:R1 100 and M+:R2 200 Full Benefit: M:R1 300 and M+:R2 750

PRODUCT HIGHLIGHTS PREVENTATIVE CARE

HEARING AIDS Preventative care Flu vaccine will be covered within the current Wellness benefit. Pneumococcal vaccine will be covered within the current Wellness benefit. Wellness benefit on Full Benefit be increased to R2 500 per family. Hearing aids 20% increase in the hearing aid benefit on the Primary Care and Affordable Care options 30% increase for Full Benefit. Removal of the two lower income bands on Gomomo Option

GOMOMO CARE

PRODUCT HIGHLIGHTS

OPTOMETRY Change from a family limit to the following cover per beneficiary Inflationary increases to the following limits  Oncology  Prosthesis  Advanced radiology  Preventative care and wellness  Day to day: Auxiliary services  Day to day: Mental health  Day to day: Chronic conditions  Day to day: Appliances  Day to day: Wheelchairs

GOMOMO CARE

6.5% Average Increase Plan Option Service Type 2017 Limit Gomomo Care -Out of hospital

This is our entry-level option. Gomomo provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network

• provider. Dentistry, radiology and pathology are also

available from a network provider. No overall limit for in-hospital at selected network hospital Covers the 27 CDL conditions

Advanced radiology limited to a combined in and out of hospital benefit 6 770 Over the counter medication 280 Chronic medication 7 450 Optical (M) -subject to 24-month cycle 1 070 Optical (M + 1) -subject to 24-month cycle 1 230 Optical (M + 2) -subject to 24-month cycle 1 370 Optical (M + 3) -subject to 24-month cycle 1 970 Dentistry (M) 2 630 Dentistry (M+1) 3 020 Dentistry (M+2) 3 290 Dentistry (M+3) 3 560 Dentistry (M+4) 3 810 Dentistry (M+5) 4 070 Dentistry (M+6) 4 470 Other services (Includes physiotherapists, speech therapists, clinical psychologists, podiatrists, equipment and external prostheses) per family subject to PMBs 2 400 Gomomo Care Option -In-hospital Overall Prosthesis benefit sub-limit- per beneficiary per annum. 26 625

HOSPITAL CARE

HOSPITAL CARE OPTION This Hospital plan offers peace of mind knowing that in the event of hospitalisation extensive cover is available at any private

• hospital. In addition the hospital care option

provides cover for 26 chronic disease list conditions. Medicines given to a patient to take home limited to a supply of seven (7) days only

HOSPITAL CARE

PREVENTATIVE CARE

Subject to the family limit of R 1 920 per annum Limited to one test per beneficiary per annum where not otherwise specified Wellness screening Includes the following tests: Blood sugar, Cholesterol, Blood pressure, Body Mass Index, HIV testing; One screening test per beneficiary per annum covered; Limited to R 300 per beneficiary per annum at a Preferred Provider facility; Other screening tests Cover limited to the following tests: Females: Mammogram every 2 years for women above age 40 years, Pap smear every 2 years for women above 21 years Males above 40 years: Prostate Specific Antigen test Vaccinations  Flu Vaccine  Pneumococcal Vaccine

Plan Option Service Type 2017 Limit Savings Care Option - Out of Hospital

This is our new generation option. Comprehensive in- hospital benefits. Out-of-hospital benefits paid from a 15% savings portion available up front for the year. No overall in-hospital limit with the freedom to go to any private hospital.

Specialised Radiology (Combined limit in and out of hospital per family per annum) 23 960 Private nursing (per family per annum) 5 750 Appliances (Memb without a dependant) 1 230 Appliances (Member with one or more dependant) 2 160 Prosthesis (per family per annum) 35 950 Mental Health (per family per annum) 7 190 Preventative care 1 920 Wellness screening (per beneficiary per annum at a Preferred Provider facility; Preauthorisation required) Pre-authorisation required. 300 Savings Care Option - In-Hospital Blood transfusions and blood replacement products 75 350 Prosthesis (Surgical and non-surgical prosthesis) 35 950 Oncology 121 920 Specialised Radiology (MRI/CAT scan/Angiogram) subject to an overall combined in and out of hospital limit 23 960 Organ Transplant and Renal Dialysis (per family per annum) 190 420

SAVINGS CARE

PRIMARY CARE

Plan Option Service Type 2017 Limit Primary Care Option -Out of hospital Primary Care option offers good value for money with unlimited hospitalisation at any private

• hospital. This traditional option has

generous day-to-day benefits which cover acute medicines, GP s, specialists, radiology, pathology and more to meet the needs of any family. Specialised Radiology (MRI/CAT scan/Angiogram) subject to an overall combined in and out of hospital limit) per family per annum 17 710 Private nursing (per family per annum) 4 310 Auxiliary services ( Member without dependant ) 960 Auxiliary services ( Member with 1 or more dependant ) 1 550 Acute meds ( M) 1 680 Acute meds (M+1) 3 030 Acute meds (M+2) 3 370 Acute meds ( M+3) 3 820 Acute meds ( M+4) 3 930 Acute meds ( M+5) 4 150 Acute meds(M+6 and more) 4 490 Appliances(Member with one or more dependant ) 960 Mental Health ( per family per annum) 1 560 Wellness screening (per beneficiary per annum at a Preferred Provider facility; Preauthorisation required) Pre-authorisation required. 255 Other screening tests (Mammogram, pap smear, PSA (Limited to one test per beneficiary per annum) subject to family limit as stated here 1 920 Female Contraceptives (per family per annum subject to Managed Care protocols and formulary 2 490 Hearing Aids ( per family ) every 4 years 5 500 Non-motorised wheelchairs (Member with or without dependants) 1 790 Primary Care In- hospital Prosthesis (per family within hospital limit as stipulated) 24 270 Specialised Radiology ((MRI/CAT scan/Angiogram) per family per annum, pre-authorisation and managed care protocols 17 710 Oncology 106 500

AFFORDABLE CARE

Plan Option Service Type 2017 Limit Affordable Care Option -Out of hospital Our Affordable Care

• ption offers generous

comprehensive cover with unlimited hospitalisation in any private hospital. It also covers additional chronic conditions with specialised dentistry and preventative benefits. Specialised Radiology MRI/CAT scan/Angiogram) subject to an overall combined in and out hospital limit 26 920 Private nursing ( per family per annum) 6 430 Clinical & Medical technology services ( member without a dependant ) 1 440 Clinical & Medical technology services ( member with 1 or more a dependants ) 2 510 Auxiliary services ( Member without dependant ) 1 440 Auxiliary services ( Member with 1 or more dependant ) 2 510 Non-PMB Chronic meds ( M)- (Subject to a maximum of R5 261 per beneficiary) 5 260 Non-PMB Chronic meds ( M+1) - (Subject to a maximum of R5 261 per beneficiary) 10 520 Non-PMB Chronic meds ( M+2) - (Subject to a maximum of R5 261 per beneficiary) 15 780 Non-PMB Chronic meds ( M+3) - (Subject to a maximum of R5 261 per beneficiary) 21 040 Non-PMB Chronic meds ( M+4) - (Subject to a maximum of R5 261 per beneficiary) 26 290 Non-PMB Chronic meds ( M+5) - (Subject to a maximum of R5 261 per beneficiary) 31 570 Non-PMB Chronic meds ( M+6 and more) - (Subject to a maximum of R5 261 per beneficiary) 36 830 All Non-PMB meds are subject to a maximum of this amount per beneficiary 5 261 Appliances (Member without a dependant) 1 440 Appliances( Member with one or more dependant ) 2 510 Mental Health ( per family per annum) 8 140 Wellness screening - One consultation visit in doctors rooms (per beneficiary per annum at a Preferred Provider facility; Preauthorisation required) Pre-authorisation required. 255 Other screening tests (Mammogram, pap smear, PSA (Limited to one test per beneficiary per annum) subject to family limit as stated here 1 920 Female Contraceptives (per family per annum subject to Managed Care protocols and formulary 2 490 Hearing Aids (per family) every 4 years 8 600 Non-motorised wheelchairs (Member with or without dependants) 2 990 Affordable Care Option -In-hospital Prosthesis (per family within hospital limit as stipulated) 40 450 Specialised Radiology ((MRI/CAT scan/Angiogram) per family per annum, pre-authorisation and managed care protocols 26 920 Refractive surgery including Radial Keratotomy (per family per annum) 5 980 Oncology 266 250

FULL BENEFIT CARE

Plan Option Service Type 2017 Limit Full Care Option -Out of hospital Our Full Benefit Care

• ption offers

comprehensive cover, generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital. Full benefit

• ffers additional chronic

conditions, specialised dentistry, GP s, specialists, acute medication, preventative care benefits and more rich benefits. This is the only option which offers additional cover when in hospital up to 200% of the Sizwe rate. Specialised Radiology ( MRI/CAT scan/Angiogram ) subject to an overall combined in and

• ut of hospital limit ) per family per annum

35 420 Private nursing ( per family per annum) 8 620 Clinical & Medical technology services ( member without a dependant ) 2 520 Clinical & Medical technology services ( member with 1 or more a dependants ) 4 060 Auxiliary services ( Member without dependant ) 2 630 Auxiliary services ( Member with 1 or more dependant ) 4 420 Non-PMB Chronic meds ( M) 10 400 Non-PMB Chronic meds ( M+1) 20 820 Non-PMB Chronic meds ( M+2) 31 110 Non-PMB Chronic meds ( M+3) 41 520 Non-PMB Chronic meds ( M+4) 51 930 Non-PMB Chronic meds ( M+5) 62 340 Non-PMB Chronic meds ( M+6 and more) 72 750 All Non-PMB meds are subject to a maximum of this amount per beneficiary 10 400 Appliances (Member without a dependant) 2 510 Appliances( Member with one or more dependant ) 4 180 Mental Health ( per family per annum) 15 680 Wellness screening (per beneficiary per annum at a Preferred Provider facility; Preauthorisation required ) Pre-authorisation required. 255 Other screening tests( Mammogram , pap smear ,PSA (Limited to one test per beneficiary per annum) subject to family limit as stated here 2 500 Female Contraceptives (per family per annum subject to Managed Care protocols and formulary 2 490 Hearing Aids ( per family ) every 4 years 12 700 Non-motorised wheelchairs (Member with or without dependants ) 4 170 Full Care Option -Out of hospital Prosthesis ( per family within hospital limit as stipulated ) 53 400 Specialised Radiology ((MRI/CAT scan/Angiogram) per family per annum, pre- authorisation and managed care protocols 35 420 Refractive surgery including Radial Keratotomy (per family per annum) 116 930 Oncology 319 500

CONTRIBUTIONS

FULL BENEFIT CARE

Income bracket Principal Member Adult Dependant Child R0 – R530 R407 R407 R407 R531 - R8 766 R 1 907 R 1 488 R 480 R8 767 + R 2 326 R 1 519 R 480 Income bracket Principal Member Adult Dependant Child R0 - R15 052 R 2 733 R 2 511 R 630 R15 053 – R18 444 R 2 843 R 2 610 R 660 R18 445 + R 3 657 R 3 251 R 730

GOMOMO CARE

Income bracket Principal Member Adult Dependant Child R0 – R18 879 R 4 210 R 3 825 R 860 R18 880 + R 4 885 R 4 441 R 960

HOSPITAL CARE SAVINGS CARE PRIMARY CARE AFFORDABLE CARE

Income bracket Principal Member Adult Dependant Child R0 – R10 112 R 1 666 R 1 546 R 410 R10 113 + R 2 060 R 1 623 R 420 Income bracket Principal Member Adult Dependant Child All R1 700 R1 300 R400 Income bracket Principal Member Adult Dependant Child R0 – R15 052 R 2 015 R 1 742 R 490 R15 053 + R 2 800 R 2 243 R 555

# caring4life

#Health Improvement Programme (HIP)

• Corporate Offering
• Membership Reward Programme
• All members commit to regular health and wellness tests

that are carried out at allocated wellness days through the year.

• A declaration of their personal goals for this period. e.g.. Lose weight, eat

healthier, start exercising, bring my cholesterol down

• Incentivize members to complete the allocated tests quarterly to receive health

and wellness related voucher when their booklet is complete.

Sizwe Baby

• From registration to expected date of

delivery, plus 12 months’ access to:

• Information and support service
• Telephonic midwife support
• Online

information, tools, resources and discount mall

• Monthly messaging (email/SMS)
• Maternity guide (courier or post)
• High risk case management
• Monthly reporting
• Maternity care pack (courier or post)

What is the Sizwe Medical Fund Gap Cover?

• It is a benefit offered exclusively to beneficiaries who have purchased Full Benefit Care option on a range of Sizwe Medical Fund plan
• ptions. It only applies to hospitalisation and surgical procedures (operations in theatre)

What are the benefits of this cover?

• Registered medical practitioners (Specialist doctors & General medical doctors) are entitled to charge scheme beneficiaries above the

rate at which the scheme pays a claim for healthcare services rendered in-hospital and out-of-hospital

• Owing to this fact, scheme beneficiaries may at times experience liability for any amount a general medical doctor or specialist doctor

charges above the scheme rate (Sizwe rate)

• Gap cover benefit will settle the difference between the scheme rate (Sizwe tariff rate) and the amount charged by registered medical

practitioners and hospital facilities

• The amount covered by Gap cover is Sizwe negotiated tariff rate plus 200% (This means that cover will be what Sizwe pays normally

plus two times the normal rate) When can a Full Care option beneficiary of Sizwe Medical Fund access this benefit?

• The benefit must be applied for within three (3) months of hospitalisation

Sizwe Medical Fund Gap Cover

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