2014 Healthcare Arrangements Presented by Nicolette du Toit AGENDA - - PowerPoint PPT Presentation
Volkswagen Group South Africa 2014 Healthcare Arrangements Presented by Nicolette du Toit AGENDA Who is Alexander Forbes? FAIS Requirements 2014 VWSA Healthcare Arrangements General On-site Assistance Scheme
AGENDA
Alexander Forbes Health’s Commitment to You
As Healthcare Consultants to VWSA we provide the following services
FAIS Requirements
33471
3064
provided
request
Medical Schemes (actuarial and consulting services)
General
subsidised. On-site Assistance (Medical Aid Office in the HR Benefits Department)
Scheme Administration
within 30 days of the event.
2014 HEALTHCARE ARRANGEMENTS
Waiting Periods & Penalties
a VWSA Scheme at date of employment.
if you change Schemes (at the end of the year). Medical Schemes & Options for 2014 (All Employees)
2014 HEALTHCARE ARRANGEMENTS
Stated benefit – R20 000
Oncology co-payment cover up to R250 000 Personal accident cover RoadCover
*Please refer to the Admed brochure in your induction pack for further detail
2014 HEALTHCARE ARRANGEMENTS
Summary of the 2014 Schemes/Plans
PLANS Primary Standard Unify Type of Plan Offers members who do not need extensive chronic medicine benefits, with affordable cover and limited day-to-day benefits. Provides comprehensive cover with extended chronic medicine cover and generous day-to-day benefits. a Managed Care plan where the selected GP acts as the “gatekeeper” to the required health services, and provides primary health benefits for the full year as medically required. Ambulance ER 24 – 084 124 Overall Annual Limit None None None HOSPITALS Private Hospitals Pre-authorisation [at least 48 hours prior to hospitalisation ] Unlimited 100% of Bonitas Rate Sub-limits apply & deductibles on listed procedures Unlimited 100% of Bonitas Rate Sub-limits apply Unlimited 100% of Medihelp Rate Sub-limits apply Cuyler Clinic: Uithge Mercantile: PE & Others
R1 000
Colonoscopy, Conservative back treatment, Cystoscopy, Facet joint injections, Flexible sigmoidoscopy, Functional nasal surgery, Gastroscopy, Umbilical hernia repair, Hysteroscopy (not Endometrial ablation), Myringotomy, Tonsillectomy and Adenoidectomy (except PMB’s), Varicose vein surgery
R2 500
Arthroscopy, Diagnostic laparoscopy, Hysterectomy (except cancer and PMB’s), Perutaneous Radiofrequency ablations, Percutaneous rhizotomies, Laparoscopic Appendectomy, Laparscopic Nephrectomy
R5 000
Nissan Fundoplication (reflux surgery), Back surgery including spinal fusion, Joint replacements e.g. hip & knee replacements (except PMB’s)Laparoscopic Pyeloplasty, Laparoscpic Radical Prostatectomy
PLANS Primary Standard Unify CHRONIC MEDICATION BENEFITS Chronic Medication 26 PMB conditions unlimited cover for PMB’s from DSP: Pharmacy Direct Telephonic Application Clinical Entry Criteria 26 PMB conditions 16 Additional conditions Paid from benefit limit
at ANY Provider (comprehensive formulary) thereafter unlimited cover for PMB’s from DSP: Pharmacy Direct Telephonic Application Clinical Entry Criteria 26 PMB conditions Subject to chosen GP or referred specialist and Network formulary Additional conditions Subject to chosen GP or referred specialist and Network formulary up to an Annual limit of R 6 600 pb All Chronic Medication must be obtained from Udipa’s Chronic Disease and Wellness Centre.
Summary of the 2014 Schemes/Plans
PLANS Primary Standard Unify TYPE OF COVER OUT OF HOSPITAL COVER
Day-to-Day non-hospital Specialists consultations (referral required), Acute medication, PAT(limits apply), Radiology, Pathology and certain auxiliary services are paid from the Day- to-Day fund. The funds belong to the Scheme No roll over/accumulation takes place Benefit limits applies to other disciplines
The member must use the selected Network GP for all Day- to-Day Doctors’ visits, Acute medication, Referral to Specialists, Radiology and Pathology. Preffered Providers: GP Network – Udipa/Ecipa Radiology – Visser & Erasmus Pathology - Pathcare
If requirements are met , above services will be covered for the full year.
OTC Medication up to R250 pfpa available from Udipa’s Chronic Disease and Wellness Centre.
Benefit limits applies to other disciplines
Day-to-Day fund Single Member : R1 600 Member+1 : R2 900 Member+2: R3 400 Member+3: R3 700 Member+4: R4 000 Day-to-Day fund Single Member : R3 600 Member+1 : R5 500 Member+2: R5 900 Member+3: R6 400 Member+4: R6 950
Summary of the 2014 Schemes/Plans
PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS GP Consultations & procedures
GP Network Benefit Limit
PM : R1 500; M+1 : R2 850; M+2: R3 300; M+3: R3 600; M+4+: R4 000
Non-Network Sub-Limit
PM : R500; M+1 : R950; M+2: R1 100; M+3: R1 200; M+4+: R1 350
GP Network Benefit Limit
PM : R3 200; M+1 : R4 400; M+2: R5 200; M+3: R5 500; M+4+: R5 900
Non-Network Sub-Limit
PM : R1 050; M+1 : R1 600; M+2: R1 750; M+3: R1 850; M+4+: R2 000
Required benefits for the full year from chosen GP Emergency Out of Network Benefit:
4 visits per family & R600 per family for medication
Member to pay and claim back from fund Also for 2nd Opinion
Specialist Consultations & procedures
Subject to Day-to-Day fund limit Specialist referral Management in all instances except: Gynaecologist: 1 visit per annum – female beneficiaries. Paediatrician visits: no referral required for children < 2 yr Oncologist visits Ophthalmologist visits Required benefits for full year; Subject to referral by chosen GP
Summary of the 2014 Schemes/Plans
PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS (continued) Optometry Either Spectacles or Contact Lenses, not both 1 Consultation: max R295 Lenses: (per lens) Clear single vision R150 Flat top Bifocal R325 Clear Multifocal R600 Frame limit: R300 Contact lenses: R750 Annual Family Limit: R3 880 2 Year Benefit Cycle for spectacles/ contact lenses
* If non-PPN Provider is used, member will be refunded and must ensure payment to provider, subject to the listed the benefit limits
1 Consultation: max R295 Lenses: (per lens) Clear single vision R150 Flat top Bifocal R325 Clear Multifocal R600 Frame limit: R800 Contact lenses: R1 550 Annual Family Limit: R5 180 2 Year Benefit Cycle for spectacles/ contact lenses
* If non-PPN Provider is used, member will be refunded and must ensure payment to provider, subject to the listed the benefit limits
Must use Network Optometrist 1 Test every year Spectacle & Contact Lens limits: M : R 954 M+1 : R 1 091 M+2 : R 1 219 M + 3 : R 1 749 Frame sub-limit: R439 2 Year Benefit Cycle for spectacles/ contact lenses
Summary of the 2014 Schemes/Plans
PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS (continued) Dentistry Basic cover only Subject to: clinical protocol Bonitas Dental Tariff Basic & Advanced Subject to: clinical protocol Bonitas Dental Tariff 20% co-payment applies to Orthodontic treatment Pre-authorisation required for Advanced Dental Services Must use Network Dentist Basic & Advanced limited to: M : R 2 332 M+ 1 : R 2 681 M+ 2 : R 2 915 M + 3 : R 3 148 M + 4 : R 3 381 M + 5 : R 3 604 M + 6 : R 3 964 Dentures included in above limits and limited to 1 set per beneficiary every 3 years.
Summary of the 2013 Schemes/Plans
PLANS Primary Standard Unify SUPPLIMENTARY BENEFITS Maternity Care
6 ante-natal consultations 2 x 2D scans 12 ante-natal consultations 2 x 2D scans R950 for ante-natal Classes Selected Network GP/referral to Specialist by Network GP 2 x 2D scans
Mental Health Benefits
R12 200 per family Pre-Authorisation Sub-limit of R7 400 for consultations in & out of Hospital R31 200 per family Pre-Authorisation Sub-limit of R12 200 for consultations in & out of Hospital Combined limit of R2 120 per family with Other Health Services
Infant Paediatric Benefit
1 consultation before the age
1 consultation between the ages of 1 to 2 pb pa 2 consultations before the age of 1 pb pa 1 consultation between the ages
Selected Network GP/referral to Specialist by Network GP
Childhood Illness Benefit
1 GP consultation pb pa between ages of 2 to 12 2 GP consultation pb pa between ages of 2 to 12 Selected Network GP
Summary of the 2014 Schemes/Plans
* On Bonitas the Supplementary Benefits are Additional Benefits that does not affect your Day-To-Day Benefit limits.
PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS (continued) Specialized Radiology: MRI/CT Scans
Joint limit with In-Hospital Scans R9 500 per family/year R20 100 per family/year 1 specialised investigation, i.e. MRI,CT scan or angiography to a max of R6 000 per family/year
Auxiliary Services
Subject to Day-to-Day fund limit: e.g. Chiropractors, Dieticians, Physiotherapy. Or Supplementary Benefits: e.g. Appliances, Prosthesis, Mental Health Benefits, Maternity Benefits. R2 120 Joint annual limit for services., Including clinical psychologists, physiotherapy speech therapy, podiatry, equipment and external prosthesis, subject to PMB
Summary of the 2014 Schemes/Plans
2014 Employee Contributions (50%)
ALL INCOME CATEGORIES Family Size PRIMARY PLAN DAY-to-DAY BENEFITS Network GP limit STANDARD PLAN DAY-to-DAY BENEFITS Network GP limit Member 706.00 1600 1500 1093.00 3600 3200 Member, Spouse 1258.50 2900 2850 2038.50 5500 4700 Member, Spouse, 1 Child 1483.50 3400 3300 2358.00 5900 5200 Member, Spouse, 2 Children 1708.50 3700 3600 2677.50 6400 5500 Member, Spouse, 3 Children + 1933.50 4000 4000 2997.00 6950 5900 Member, 1 Child 931.00 1600 2850 1412.50 5500 4700 Member, 2 Children 1156.00 3400 3300 1732.00 5900 5200 Member, 3 Children + 1381.00 3700 3600 2051.50 6400 5500 1 Un-subsidised Adult 1105.00 TBD TBD 1891.00 TBD TBD 2 Un-subsidised Adults 2210.00 TBD TBD 3782.00 TBD TBD
TBD: The day-to-day values and GP benefit limits are determined based on the overall family size and not per dependant Please note that these rate tables have been calculated up to the 3rd child.
and required proof is supplied annually.
2014 Employee Contributions (50%)
MONTHLY INCOME Family Size <= 3000 3001 to 5000 5001 to 7000 7001 to 9000 => 9001 Member 489.00 546.00 657.00 708.00 879.00 Member, Spouse 879.00 1056.00 1290.00 1368.00 1572.00 Member, Spouse, 1 Child 990.00 1179.00 1449.00 1536.00 1746.00 Member, Spouse, 2 Children 1101.00 1302.00 1608.00 1704.00 1920.00 Member, Spouse, 3 Children 1212.00 1425.00 1767.00 1872.00 2094.00 Member, 1 Child 600.00 669.00 816.00 876.00 1053.00 Member, 2 Children 711.00 792.00 975.00 1044.00 1227.00 Member, 3 Children 822.00 915.00 1134.00 1212.00 1401.00 1 Un-subsidised Adult 780.00 1020.00 1266.00 1320.00 1386.00 2 Un-subsidised Adults 1560.00 2040.00 2532.00 2640.00 2772.00
Please note that these rate tables have been calculated up to the 3rd child.
to add a further contribution in respect to each additional child i.e.
child, is charged a rate equal to the adult dependant rate, even if they are under the age of 24.
MONTHLY INCOME <= 3000 3001 to 5000 5001 to 7000 7001 to 9000 => 9001 Per additional Child (50%) 111.00 123.00 159.00 168.00 174.00
When you need assistance:
Contact your dedicated Alexander Forbes consultants: Nicolette du Toit and Felicia Gounder Give us a call on (041) 392 8329 and (041) 392 8304 or Email us at dutoitni@aforbes.co.za and gounderf@aforbes.co.za EC Client Specialist Division: or Let us call You! Tel: (041) 392 8304 SMS the word “medical aid ec” to 31768 E-mail: afhealthec@aforbes.co.za and one of our consultants will call you back. (sms charged at standard rates) Visit your dedicated Alexander Forbes Website: http://www.afhealth.co.za/vwsa Contact your Scheme Directly: Bonitas 0860 00 21 08 (24 hrs) or access their website at www.bonitasmedicalfund.co.za Medihelp 0860 10 06 78 (24 hrs) or access their website at www.medihelp.co.za To keep your finger on the pulse of the Medical Scheme industry, follow us