DSP 100 Medihelp Necesse Plan Comparison 2013
User Manual: DSP-100
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Necesse is Medihelp’s income-based network option which offers primary and hospital care at a network of private providers at a highly competitive rate. necesse • Necesse subscription is based on three income categories ranging from R7,500 or less to the highest category of R11,001 and more ensuring that low incomeearners are also provided access to quality private healthcare. • Acute medicine on the approved Necesse medicine list (formulary) is available from your dispensing network doctor or on prescription from a Medihelp network pharmacy. Pre-authorised chronic medicine for CDL conditions included. Income-based subscription • • Medicine • • • • Necesse offers a hospital network of over 120 private facilities nationwide. Your Necesse network doctor or specialist on referral should admit you to hospital. Hospital admissions require a referral from your Necesse doctor or specialist and must be pre-authorised. Emergency admissions can be authorised on the first workday after admission. Emergency transport services are provided by ER24. • • H • Choose any doctor within the Necesse network of over 1,200 GPs nationwide. Visit our website at www.medihelp.co.za or dial *120*6364# on your cell phone for a list of network doctors. Authorised specialist visits on referral from your Necesse network doctor. Basic dental services provided by a network of over 1,000 dentists. Optometry benefits are provided by a nationwide network of more than 2,000 optometrists. Pathology services provided by a network of providers. Hospitalisation Day-to-day benefits This option has no overall annual limit and focuses on making private healthcare services more accessible. Contributions are based on income and a network of private healthcare professionals provides access to quality care. Please visit our website at www.medihelp.co.za for lists of network providers • • necesse (network option) 18 100% of the contracted tariff Necesse formulary applies Co-payments apply if services are rendered by non-preferred providers Gynaecologist services on referral by a Necesse network doctor Sonars (2D) on referral by a Necesse network doctor or specialist • • 100% of the scheme tariff 2 two-dimensional sonars per beneficiary 100% of the scheme tariff 2 consultations per beneficiary 20% co-payment if not on referral PREGNANCY (SUBJECT TO PREAUTHORISATION AND TREATMENT GUIDELINES) 100% of the scheme tariff • Pre- and post-natal care provided by a Necesse network doctor • Midwife services by a registered practising nurse Pregnancy benefits BASIC PATHOLOGY (BLOOD TESTS) (LANCET OR PATHCARE) BASIC RADIOLOGY (X-RAYS) REQUESTED BY A NECESSE NETWORK DOCTOR • Black and white X-rays and soft-tissue ultrasounds 100% of the scheme tariff Necesse formulary applies 100% of the scheme tariff 20% co-payment if not pre-authorised OXYGEN Services rendered not during hospitalisation X-rays and blood tests 100% of the Necesse formulary Co-payments may apply 100% of the scheme tariff R200 per beneficiary per year, maximum R68 per event 100% of the contracted tariff According to formulary Co-payments may apply 100% of the scheme tariff Pre-authorisation from the 9th consultation per family per year onwards AUTHORISED CHRONIC MEDICINE PRESCRIBED BY A NECESSE NETWORK DOCTOR – PMB MEDICINE ONLY OVER-THE-COUNTER (OTC) MEDICINE ACUTE MEDICINE PRESCRIBED BY A NECESSE NETWORK DOCTOR GENERAL PRACTITIONER SERVICES WITHIN THE NECESSE NETWORK • Consultations 100% of the contracted/scheme tariff/medicine price R9,000 per event for home delivery HOME DELIVERY Subject to pre-authorisation • Professional nursing fee • Equipment • Material and medicine • Lenses One pair of standard high-quality clear lenses Contact lenses • Spectacles or contact lenses Benefits are limited to either spectacles or contact lenses • Spectacles • Frame R395 (only PPN optometrists) Clear single vision lenses or Clear Aquity bifocal lenses R150 (PPN frame) Benefits are available per 2-year cycle 1 comprehensive consultation, including refraction test, tonometry and visual fields test PHYSIOTHERAPY AND OCCUPATIONAL THERAPY MUST BE REQUESTED BY A NECESSE NETWORK DOCTOR 100% of the scheme tariff R1,460 per member per year or R2,240 per family per year Physiotherapy and occupational therapy • OPTICAL SERVICES (PPN) Optometric examinations Eye test and spectacles or contact lenses 100% of the contracted tariff In the case of an elective caesarean section - R17,970 per confinement 20% co-payment per unauthorised non-emergency admission or services rendered by a non-network hospital 100% of the contracted tariff Unlimited 20% co-payment per unauthorised non-emergency admission or services rendered by a non-network hospital Benefit MATERNITY �non�PMB cases� Subject to pre-authorisation and clinical protocols • Hospitalisation • Midwifery and confinement/delivery • Gynaecologist and anaesthetist services MATERNITY �PMB cases� Subject to pre-authorisation and clinical protocols • Hospitalisation • Midwifery and confinement/delivery • Gynaecologist and anaesthetist services Description Description Benefit Maternity benefits GP visits, medicine and oxygen 19 Fillings (Item codes: 8341/8342/8343/8344/ 8351/8352/8353/8354) Root canal therapy and extractions Medicine prescribed by a dentist Plastic dentures Including associated laboratory costs Laughing gas in Denis network dentist’s rooms Dental procedures under conscious sedation in the Denis network dentist’s chair for extensive dental treatment only Subject to pre-authorisation X-rays: Intra-oral X-rays: Extra-oral • • • • • • • • Diagnostic endoscopic procedures performed in the specialist’s rooms • 100% of the contracted/scheme tariff R2,240 per single member or R3,180 per family per year 20% co-payment on consultation if not referred by a Necesse network doctor Benefits are subject to pre-authorisation by Medihelp 1 per beneficiary in a 3-year period 4 per beneficiary per year 100% of the Medihelp Dental Tariff 100% of the Medihelp Dental Tariff 1 set of plastic dentures (an upper and lower set) per family in a 24-month cycle for patients 21 years and older Co-payment of 20% on Medihelp Dental Tariff applies For member’s account 100% of the Medihelp Dental Tariff Limited to 2 teeth per beneficiary per year 100% of the Medihelp Dental Tariff 4 teeth per beneficiary, once per tooth in 365 days 100% of the Medihelp Dental Tariff 1 scale and polish treatment per beneficiary per year 100% of the Medihelp Dental Tariff 1 consultation per beneficiary per year AUTHORISED CHRONIC PMB MEDICINE 100% of the Necesse formulary PRESCRIBED BY A SPECIALIST ON REFERRAL Co-payments may apply BASIC RADIOLOGY AND PATHOLOGY (LANCET OR PATHCARE) ACUTE MEDICINE PRESCRIBED BY A SPECIALIST MUST BE OBTAINED FROM A NETWORK PHARMACY Surgical and non-surgical procedures • SPECIALIST CARE • Specialist consultations Specialist care Oral hygiene Fluoride treatments (Item codes: 8155/8159) and fissure sealants for children <16 only (Item code: 8161) • BASIC CONSERVATIVE DENTAL SERVICES MUST BE PROVIDED BY A DENTIST IN THE DENTAL INFORMATION SYSTEMS (DENIS) NETWORK Subject to clinical treatment guidelines and managed care interventions • Routine check-ups (full mouth examination) PHYSIOTHERAPY AND OCCUPATIONAL THERAPY During hospitalisation MAXILLOFACIAL SURGERY DUE TO TRAUMA�RELATED INJURIES � PMB ONLY Subject to pre-authorisation and clinical protocols APPLICABLE MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON THE DAY OF DISCHARGE FROM HOSPITAL (TTO) HOSPITALISATION Subject to pre-registration, pre-authorisation, protocols and case management • Intensive care units and high-care wards • Ward accommodation • Theatre costs • Consultations by network general practitioners or specialists • Treatment and ward medicine • Surgery and anaesthesia Hospitalisation ER24 TRAUMA COUNSELLING 24-HOUR HELPLINE (ER24) EMERGENCY TRANSPORT SERVICES ARE PROVIDED AND PRE-AUTHORISED BY ER24 • Emergency transport services by road/air within the borders of South Africa only EMERGENCY VISITS (NON-PMB CASES) AND OUT-OF-NETWORK CONSULTATIONS • Outpatient and emergency consultations (non-PMB cases) • Medicine and services rendered by a nonnetwork general practitioner • Pathology requested by a non-network general practitioner (Lancet or Pathcare) according to list of pathology codes • Radiology • Facility fee EMERGENCIES (PMB) Subject to the definition on p29 Description Description Benefit Emergency services Basic dental services 100% of the scheme tariff R6,740 per family per year 100% of the cost 100% of the medicine price R260 per admission 100% of the contracted/scheme tariff/medicine price Unlimited 20% co-payment per unauthorised non-emergency admission or admission to a non-network hospital Phone 084 124 for advice in a medical emergency 100% of the contracted tariff/cost For member’s account 80% of the scheme tarrif R780 per member per year R1,560 per family per year 100% of the cost Unlimited Benefit 20 Extensive dental treatment for very young children only 100% of the scheme tariff R11,230 per family per year 20% co-payment per unauthorised non-emergency or services rendered by a non-network hospital DTP – Diagnosis Treatment Pairs CDL – Chronic Diseases List 100% of the contracted tariff R15,150 per family per year 20% co-payment per unauthorised admission to sub-acute care facilities General day-to-day care excluded (such as bathing) ICON – Independant Clinical Oncology Network SUB-ACUTE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation and case management Sub-acute and private nursing services SPECIALISED RADIOLOGY REQUESTED BY A SPECIALIST ON REFERRAL Services rendered during and not during hospitalisation must be pre-authorised • MRI and CT scans Specialised radiology • DENTAL SURGERY UNDER GENERAL ANAESTHESIA IN A HOSPITAL/DAY CLINIC ONLY Benefits are subject to pre-authorisation, Denis clinical protocols, referral and rendered by a Denis network dentist. • Trauma cases (PMB only) 100% of the cost 100% of the scheme tariff R15,150 per family per year CLINICAL TECHNOLOGIST SERVICES Services rendered during hospitalisation Dental surgery 100% of the scheme tariff R15,150 per family per year BLOOD TRANSFUSION SERVICES AND THE TRANSPORT OF BLOOD AND BLOOD PRODUCTS Services rendered during and not during hospitalisation 100% of the scheme tariff/cost 100% of the cost Unlimited Co-payments may apply 100% of the cost Unlimited Co-payments may apply Subject to registration on the management programme provided by Optipharm 100% of the cost Unlimited Co-payments may apply Subject to registration on the management programme provided by ICON 100% of the cost Unlimited Co-payments may apply Applicable medicine dispensed and charged by the hospital on the day of discharge from hospital External prosthesis SURGICAL AND ORTHOPAEDIC APPLIANCES REQUIRED DURING HOSPITALISATION • PROSTHESES � PMB ONLY • Internally implanted prosthesis RENAL DIALYSIS � PMB ONLY (acute and chronic) • Rendered by a designated service provider • 100% of the scheme tariff/cost R6,740 per family per year 100% of the scheme tariff/cost 100% of the contracted tariff Subject to pre-authorisation and enrolment on the dialysis management programme 100% of the medicine price R260 per admission TREATMENT OF A MENTAL HEALTH CONDITION � PMB ONLY Subject to pre-registration, pre-authorisation, 100% of the contracted/scheme tariff/medicine price 20% co-payment applies to non-authorised and nonprotocols and case management network hospital admissions • Professional psychiatric services • Ward accommodation • Medicine and materials supplied or administered during hospitalisation POST-EXPOSURE PROPHYLAXIS (Provided by Optipharm) BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION HIV/AIDS (Optipharm) • Antiretroviral therapy and treatment by DSP ONCOLOGY � PMB ONLY • Chemotherapy and radiotherapy • Surgery BASIC RADIOLOGY During hospitalisation OXYGEN Services rendered during hospitalisation DIAGNOSIS, CARE AND TREATMENT OF 270 DTP AND MEDICINE FOR 26 CDL CONDITIONS (SUBJECT TO ALGORITHMS, PROTOCOLS AND PRE-AUTHORISATION) PATHOLOGY AND MEDICAL TECHNOLOGY During hospitalisation Pathology services should be rendered by 100% of the contracted/scheme tariff Lancet or Pathcare R20,780 per family per year Benefit Description Description Benefit Prescribed Minimum Benefits (PMB) Hospitalisation 21 R654 R354 Adult dependant Child dependant < 21 years R444 R798 R1,020 R7,501 to R11,000 R510 R924 R1,182 R11,001 and more This is a summary of the Necesse benefit option. In the case of a dispute, the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes. All limits are valid for one year, unless otherwise indicated. If a beneficiary joins during the course of a financial year, the benefits (limits) are calculated pro rata according to the remaining number of months per year. * If the member’s gross monthly income (before deductions) is more than R11,001, no proof of income is required. R828 Principal member R7,500 or less *Gross monthly income of principal member Latest tax assessment – ITA 34 Letter of auditor/accountant/tax adviser Past three months’ commission and bank statements* Latest tax assessment – ITA 34 Letter of auditor/accountant UIF payments and bank statements* Income of person paying the subscriptions Latest tax assessment – ITA 34 Past three months’ bank statements* indicating the pension deposits Past three months’ pension payment advices Notice/letter on official letterhead of tertiary institution where registered A copy of relevant year’s student card Self-employment Income from vocation/profession Total income from business Trusts Income from trusts Unemployment Individuals who earn no income from a vocation/profession/business Pensions and annuities Income from pensions or annuities Full-time students (Members without dependants) * Only bank statements indicating the account holder’s initials and surname will be accepted. Please indicate clearly which payment refers to your income. Letter of auditor/accountant/tax adviser Latest tax assessment – ITA 34 IT3(a) and past three months’ bank statements* Rental income – rental agreement and past three months’ bank statements* indicating deposists Past three months’ official pay slips Latest tax assessment – ITA 34 IRP 5 of previous tax year Past three months’ commission and bank statements* Acceptable proof of income Investments Interest Dividends Rental income Full-time employment Basic salary, overtime, commission Bonuses (all types, e.g. 13th cheque, production bonus etc.) Allowances (all types, e.g. car/travelling, cell phone etc.) Fringe benefits (e.g. company car) Source If no proof of income can be provided your subscription will be based on the highest income category. Member Subscription proof of income monthly contribution 22 Account H Other referrals Your network doctor or the specialist you’ve been referred to must refer you to a physiotherapist, occupational therapist, pathologist, radiologist or other medical practitioner if required. Hospitalisation Emergencies Please remember that only emergencies which meet the definition of an emergency on this brochure (see “Explanation of terms”) will qualify for Prescribed Minimum Benefits (PMB) and must be registered as such with Medihelp. Acute medicine If referred you may only be admitted to a Necesse network hospital. If not, a 20% co-payment on the hospital account will apply. All hospital admissions, including for psychiatric admissions, must be pre-authorised (and emergency admissions on the first workday following the admission). Your network GP will refer you to a specialist if required. This entails that your network doctor completes a specialist referral form which will be used to obtain pre-authorisation for the specialist visit from Medihelp. The Necesse network doctor and other medical practitioners will submit claims directly to Medihelp. If you have paid the account yourself, you can submit qualifying claims to Medihelp for a refund. Should you require medicine, your network GP will provide you with the medicine if he/she is a dispensing doctor, or he/she will provide you with a prescription for medicine listed on the Necesse formulary. Medicine on prescription must be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Specialists 23 Only chronic medicine prescribed for the treatment of diseases on the Chronic Diseases List (CDL) will qualify for benefits. Chronic medicine must be registered with Medihelp. Your network doctor will complete an application form to register the chronic medicine and you will receive a schedule of all authorised medicine. Authorised chronic medicine should be obtained from a pharmacy or courier pharmacy in the Medihelp Preferred Pharmacy Network. You must choose a general practitioner (GP) in the Necesse network to visit. Your network doctor will refer you to a physiotherapist, specialist and other medical practitioners if required. You have to obtain pre-authorisation from Medihelp from your 9th consultation (the family’s visits combined) onwards by sending an SMS to Medihelp. Claims Chronic medicine Doctors’ visits more about necesse need to know more... Tel: 086 0100 678 Fax: 086 0064 762 oncology@medihelp.co.za The SAOC is the South African Oncology Consortium, the professional affiliation of South African oncologists who determine the guidelines according to which patients receive cancer treatment. SAOC Tel: 086 0103 529 or 086 1101 477 www.ppn.co.za The Preferred Provider Negotiators (PPN) optical providers manage Medihelp’s optical benefits. More than 2,000 optometrists across South Africa are part of the PPN network. Although Medihelp members may visit any optometrist, benefits will be paid according to the PPN tariffs and a co-payment may be applicable should the costs exceed the benefit amount. PPN Tel: 086 0906 090 Emergencies: 083 564 9978 Fax: 086 0064 762 medihelp@optipharm.co.za Optipharm is the preferred provider for the rendering of HIV/Aids-related services and post-exposure prophylaxis in the case of sexual assault or accidental exposure to HIV. Optipharm Medihelp Preferred Pharmacy Network refers to pharmacies offering Medihelp the most cost-effective professional fee structure for prescribed medicine. While standard co-payments on medicine still apply as set out in the rules of the benefit options, members who make use of network pharmacies will not have to pay any excess amounts in respect of higher professional fees charged by pharmacies to dispense medicine items. Medihelp Preferred Pharmacy Network Tel: 086 0104 941 Fax: 086 6770 336 medihelpenq@denis.co.za Dental Information Systems (Denis) is South Africa’s leading dental benefit management company. Medihelp’s dental benefits are managed by Denis and granted in accordance with Denis protocols, while Medihelp members obtain services from their regular dentists. In certain cases (particularly for specialised dentistry), benefits are subject to approval by Denis. Dental Information Systems (Denis) more about our partners This countrywide network must be used by members of the Dimension Prime Network benefit options when they need to have planned procedures performed in hospital. Members pay a lower monthly fee when they opt to make use of this network. The hospital network consists mainly of Netcare, Life and MediClinic hospitals and a complete list is available on our website. Dimension Prime Hospital Network This network of more than 120 facilities offers Necesse members access to tertiary (hospital) care. The network has a national footprint and consists mainly of Netcare, Life and MediClinic hospitals. Please visit our website for a full list of network hospitals. Necesse Hospital Network Members of the Necesse benefit option can visit one of the more than 1,200 general practitioners (GPs) located nationwide for quality primary healthcare. Please visit our website at www.medihelp.co.za for a full list of network doctors. Alternatively you can dial *120*6364# on your cell phone to locate a network GP near you. Necesse Doctor Network ICON is the Independent Clinical Oncology Network that determines clinical protocols according to which patients of the Necesse benefit option receive cancer treatment from ICON network doctors. ICON (Necesse) Document-based Care (DBC) offers a back treatment programme as prerequisite for spinal column surgery to members who qualify, and if there is a DBC clinic in their vicinity. This programme is developed by a multi-disciplinary medical team according to the patient’s clinical profile. DBC Tel: 084 124 Our partner providing all emergency medical services is ER24. They offer emergency medical transport, assistance and trauma counselling to Medihelp members. ER24 25 MDT = Medihelp Dental Tariff Dimension Elite For member’s account 100% of the MDT For member’s account 100% of the MDT Trauma cases (PMB only) 100% of the MDT Extensive dental treatment only For member’s account 100% of the MDT R2,300 co-payment per admission 100% of the MDT Savings account 100% of the MDT R1,500 co-payment per admission 100% of the MDT Savings account For member’s account 100% of the MDT R640 co-payment per admission 100% of the MDT 100% of the MDT R650 co-payment per admission 100% of the MDT Extensive dental treatment only 1 per beneficiary in a 3-year period 100% of the MDT Removal of impacted teeth and extensive dental treatment only 100% of the MDT Removal of impacted teeth only 1 per beneficiary in a 3-year period 100% of the MDT 100% of the MDT 2 partial frames (upper and lower jaw) per beneficiary every 5 year period 100% of the MDT 2 crowns per family per year, once per tooth every 5 year period 100% of the MDT R8,000 per beneficiary younger than 18 years per lifetime 100% of the MDT 1 set (upper and lower jaw) per beneficiary every 4 year period 100% of the MDT 100% of the MDT 1 filling per tooth in 365 days 100% of the MDT 2 per beneficiary per year 100% of the MDT 2 scale and polish treatments per beneficiary per year 100% of the MDT 1 partial frame (upper or lower jaw) per beneficiary every 5 year period 100% of the MDT 1 crown per family per year, once per tooth every 5 year period 100% of the MDT R6,000 per beneficiary younger than 18 years per lifetime Dimension Prime 3 100% of the MDT 100% of the MDT Savings account Dimension Prime 2 4 per beneficiary per year For member’s account Dimension Prime 1 Please refer to dental exclusions and protocols per option. • Dental surgery under general anaesthesia in a hospital/day clinic only • Removal of impacted teeth under general anaesthesia in a hospital/day clinic only • Laughing gas (in the dentist’s chair) • Maxillofacial surgery and oral pathology Surgery in the dentist’s chair • Benefits for temporomandibular joint (TMJ) therapy is limited to non-surgical interventions/ treatment • Orthodontic treatment Fixed braces – only one beneficiary per family may begin orthodontic treatment per calender year • Periodontal treatment Subject to registration on the Perio Programme • X-rays • Intra-oral • Extra oral • Dental procedures under conscious sedation in the dentist’s chair (sedation cost) • Dentist’s account • Crown and bridge work • Partial metal frame dentures • Tooth extractions and root canal treatment in the dentist’s chair • Plastic dentures (including professional and dental laboratory fees) • Fillings A treatment plan and X-rays may be required for multiple fillings For member’s account 100% of the MDT 1 per beneficiary per year 100% of the MDT 1 scale and polish treatment and fissure sealants for beneficiaries <16 Limited to Denis item codes 100% of the MDT 4 teeth per beneficiary, once per tooth in 365 days Limited to Denis item codes 100% of the MDT 2 teeth per beneficiary per year 100% of the MDT 1 set (upper and lower jaw) per family in a 24-month cycle for patients >21 years Co-payment of 20% on total cost applies • Routine examinations (check-ups) • Oral hygiene Necesse Description All benefits are subject to Denis protocols, and pre-authorisation in the case of specialised dentistry. more about dental benefits 26 Implants • Dolder bars and associated abutments on implants, including the laboratory cost. • Laboratory delivery fees. Crown and bridge work • Crown and bridge procedures for cosmetic reasons and the associated laboratory costs. • Crown and bridge procedures where there is no extensive tooth structure loss and associated laboratory costs. • Full mouth rehabilitations and the associated laboratory costs. • Provisional crowns and the associated laboratory costs. • Porcelain veneers, inlays and the associated laboratory costs. • Emergency crowns that are not placed for immediate protection in tooth injury, and the associated laboratory costs. • Cost of gold, precious metal, semi-precious metal and platinum foil. • Laboratory delivery fees. Partial metal frame dentures • Metal base to full dentures, including the laboratory cost. • High impact acrylic. • Cost of gold, precious metal, semi-precious metal and platinum foil. • Laboratory delivery fees. Plastic dentures/snoring appliances/mouth guards • Diagnostic dentures and the associated laboratory costs. • Snoring appliances and the associated laboratory costs. • Provisional dentures and associated laboratory costs. • The clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures. (The laboratory fee will be covered at the Medihelp Dental Tariff where managed care protocols apply.) • The laboratory cost associated with mouth guards. (The clinical fee will be covered at the Medihelp Dental Tariff where managed care protocols apply.) • High impact acrylic. • Cost of gold, precious metal, semi-precious metal and platinum foil. • Laboratory delivery fees. Root canal therapy and extractions • Root canal therapy on primary (milk) teeth. • Direct and indirect pulp capping procedures. Fillings/restorations • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis. • Resin bonding for restorations charged as a separate procedure to the restoration. • Polishing of restorations. • Gold foil restorations. • Ozone therapy. • Replacement of amalgam (silver) fillings with composite (white) fillings. • Tooth-coloured fillings on molars and premolars (Necesse). Oral hygiene • Oral hygiene instruction and evaluation. • Professionally applied adult fluoride. • Dental bleaching. • Nutritional and tobacco counselling. • Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments. • Fissure sealants on patients 16 years and older. dental exclusions Additional Scheme exclusions • Special reports. • Dental testimony, including dento-legal fees. • Behaviour management. • Intramuscular and subcutaneous injections. • Procedures that are defined as unusual circumstances and unlisted procedures. • Appointments not kept. • Treatment plan completed (code 8120). • Electrognathographic recordings, pantographic recordings and other such electronic analyses. • Caries susceptibility and microbiological tests. • Pulp tests. • Cost of mineral trioxide. • Enamel microabrasion. • Medicine prescribed by a dentist (Necesse). • Specialised dentistry: crowns and bridges, implants, orthodontics, periodontics and maxillofacial surgery (Necesse). Hospitalisation (general anaesthetic) • Where the reason for admission to hospital is dental fear or anxiety. • Multiple hospital admissions. • Where the only reason for admission to hospital is to acquire a sterile facility. • The cost of dental materials for procedures performed under general anaesthesia. • The hospital and anaesthetist claims for the following procedures will not be covered when performed under general anaesthesia: • Apicectomies. • Dentectomies. • Frenectomies. • Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults. • Professional oral hygiene procedures. • Implantology and associated surgical procedures. • Surgical tooth exposure for orthodontic reasons. • Removal of impacted teeth in hospital (Necesse). Maxillofacial surgery and oral pathology • Orthognathic (jaw correction) surgery and any related hospital cost and laboratory costs. • Bone augmentations. • Bone and other tissue regeneration procedures. • Cost of bone regeneration material. • The auto-transplantation of teeth. • Sinus lift procedures. • The closure of an oral-antral opening (item code 8909) when claimed during the same visit with impacted teeth (item codes 8941, 8943 and 8945). Periodontics • Surgical periodontics, which includes gingivectomies, periodontal flap surgery, tissue grafting and hemisection of a tooth. • Perio chip placement. Orthodontics • Orthodontic treatment for cosmetic reasons and associated laboratory costs. • Orthodontic treatment for persons 18 years and older. • Orthodontic re-treatment and the associated laboratory costs. • Cost of invisible retainer material. • Laboratory delivery fees. 27 Medical conditions • The treatment of infertility, other than that stipulated in the Regulations to the Medical Schemes Act, 1998. • Treatment of alcoholism and drug abuse as well as services rendered by institutions which are registered in terms of the Prevention of and Treatment for Substance Abuse Act, 2008 (Act No 70 of 2008) or other institutions whose services are of a similar nature, other than stipulated in the Regulations to the Medical Schemes Act, 1998. • Treatment of impotence. • Treatment of occupational diseases. • Hymenectomy (Dimension Prime 1 and Necesse). • Back and neck fusion procedures, subject to PMB (Necesse). • Circumcision (Necesse). General • Services which are not mentioned in the Rules as well as services which in the opinion of the Board of Trustees, are not aimed at the generally accepted medical treatment of an actual or a suspected medical condition or handicap, which is harmful or threatening to necessary bodily functions (the process of ageing is not considered to be a suspected medical condition or handicap). • Travelling and accommodation/lodging costs, including meals as well as administration costs of a beneficiary and/or service provider. • Aptitude, intelligence/IQ and similar tests as well as the treatment of learning problems. • Operations, treatments and procedures – • of own choice; • for cosmetic purposes; and • for the treatment of obesity, with the exception of the treatment of obesity which is motivated by a medical specialist as life-threatening and approved beforehand by Medihelp. • Treatment of wilfully self-inflicted injuries, unless it is a prescribed minimum benefit. • Services which are claimable from the Compensation Commissioner, an employer or any other party, subject to the stipulations of rule 15.4. • The completion of medical and other questionnaires/certificates not requested by Medihelp and the services related thereto. • Costs for evidence in a lawsuit. • Costs exceeding the scheme tariff for a service or the maximum benefit to which a member is entitled, subject to Annexure 2. • Facility fees. • Services rendered to beneficiaries outside the Medihelp network or if voluntarily obtained from a nondesignated service provider in the case of a PMB condition (Necesse). • Injuries sustained during participation in a strike, unlawful demonstration, unrest or violent conduct, except in the case of a prescribed minimum benefit (Necesse). • Services rendered outside the borders of the Republic of South Africa (Necesse). dimension range and necesse general exclusions Medicines, consumables and other products • Bandages, cotton wool dressings and plasters on prescription that are not used by a supplier of service during a treatment/procedure. • Food substitutes, food supplements and patent food, including baby food. • Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics). • Slimming remedies, provided that benefits shall be considered if motivated by a medical specialist as life-essential to be used for a limited period, and if approved beforehand by the Principal Officer. Procedures and services • The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of 2003). • Immunisation (including immunisation procedures and material) which is required by an employer, excluding flu immunisations and standard child immunisations. • Standard immunisation (Necesse). • Exercise, guidance and rehabilitation programmes. • Services rendered by social workers. • Costs of visits at home and home programmes. • When only accommodation is provided and/or general care services rendered. • The cost of transport with an ambulance/emergency vehicle – • from a hospital/other institution to a residence; • in the event of a self-inflicted injury, unless it is a prescribed minimum benefit; • in the event of a visit to friends/family; and • to the rooms of a medical practitioner when the objective of the visit/consultation/treatment does not pertain to admission in a hospital. • The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells, for future use thereof to treat a medical condition which has not yet been diagnosed in a beneficiary. • Pathology services requested by a person other than a medical practitioner. • Radiology services requested by a person other than a medical practitioner, with the exception of a chiropractor who may request black and white X-rays. • Breast augmentation. • Breast reduction. • Gastroplasty. • Gender reversal operations. • Lipectomy. • Epilation. • Otoplasty/reconstruction of the ear. • Refractive procedures. • Sclerotherapy. • Hip, knee and shoulder replacements (Necesse). 28 Appliances • Blood pressure and peak flow measurement apparatus. • Motorised mobility aids/devices. • Commode. • Toilet seat raiser. • Hospital beds for use at home. • Devices to improve sight, other than spectacles and contact lenses. • Mattresses and pillows. • Bras without external breast prostheses. • Insulin pumps and consumables (available only on Dimension Elite). • Hearing aids and services rendered by audiologists and acousticians (Necesse). • All patent substances, suntan lotions, anabolic steroids, contact lens solutions as well as substances not registered by the South African Medicines Control Council, except medicine items approved by Medihelp in the following instances – • medicine items with patient-specific exemptions in terms of section 21 of the Medicines and Related Substances Control Act, 1965 (Act No 101 of 1965) as amended; • homeopathic and naturopathic medicine items that have valid NAPPI codes; and • where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness. • All biological and other medicine items as per Medihelp’s medicine exclusion list. • High technology treatment modalities, surgical devices and medication. • Combination analgesic medicine claimed from acute medicine benefits exceeding 360 units per beneficiary per year. • Non-steroidal anti-inflammatory medicine claimed from acute medicine benefits exceeding 180 units per beneficiary per year. • Roaccutane and Retin A, or any skin-lightening agents (Necesse). • Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous household product of a medicinal nature (Necesse). • Oral contraceptives and contraceptive intra-uterine devices (Necesse). • Medicine used in the treatment of a non-PMB/CDL chronic condition (Necesse). • Vaccines administered by specialists (Necesse). EVARS prostheses shall only be considered where the patient suffers from an abdominal aortic aneurysm with an accompanying high risk for anaesthesia. DTP is Diagnosis Treatment Pairs An emergency medical condition means any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. An emergency medical condition must be certified as such by a medical practitioner. Emergencies qualify for PMB and must therefore also be registered for PMB (see also “PMB”). Co-payments are the difference between the cover provided by Medihelp and the cost/tariff charged for the medical service, and are payable directly to the service provider. Members must make co-payments in the following cases: • When doctors and other providers of medical services charge fees which exceed Medihelp’s scheme tariffs, the member is responsible for paying the difference between the amount charged and the amount which Medihelp pays; • When Medihelp’s benefit allocation is not 100% (e.g. for acute medicine), or where the cost exceeds the limit available for the service (e.g. for medical, surgical and orthopaedic appliances); and • When the member chooses not to obtain services from a designated service provider (e.g. the SAOC network in the case of oncology) or when a pre-determined co-payment is applicable to a specific benefit as indicated per benefit option. Contracted tariff is the tariff as approved by the Board of Trustees and contractually agreed with service providers, which includes per diem, fixed and global fees. Chronic medicine is medicine used for the long-term treatment (three months or longer) of a chronic condition, and which meets the following requirements: • It must be used to prevent and treat a serious medical condition; • It must be used for an uninterrupted period of three months or longer; • It must be used to sustain life, to delay the progress of a disease, and to repair natural physiology; • It must be registered in South Africa for the treatment of the medical condition for which it is prescribed; and • It must be the accepted treatment according to local and international treatment protocols and algorithms. MEDICHRON (Medihelp’s medicine management division) considers benefits for all chronic medicine. The back treatment programme is a non-surgical intervention in lieu of surgery for the management of spinal column disease/conditions/abnormalities. This approach to the treatment of back and neck pain is used as an alternative to back surgery, and involves an inter-disciplinary team handling the rehabilitation programme, which is individualised for each patient based on the patient’s needs and clinical diagnosis. The programme is not available on the Necesse network option. explanation of terms 29 Scheme tariff is the tariff for medical services as approved by the Board of Trustees. Medicine means a substance or mixture of substances which is accepted as being ethical by medical science and which is registered with the South African Medicines Control Council, to be administered or applied for the prevention, treatment or healing of an illness (see also “chronic medicine”). Medicine price refers to: • The Maximum Medical Aid Price (MMAP) which is the reference price used by Medihelp to determine benefits for acute and chronic medicine. The MMAP is the average price of all the available generic equivalents for an ethical patented medicine item; or • The Medihelp Reference Price (MHRP) which is applicable to all pre-authorised PMB medicine. The Protocols are clinical guidelines compiled by experts in the field of a specific medical condition for the treatment of that condition based on best practice principles. Maxillofacial surgery means services pertaining to the jaws and face, particularly with reference to specialised surgery in this region. Vascular/cardiac prostheses include artificial aortic valves, pacemakers and related or connected functional appliances. Unlimited means that no overall annual limit (benefit amount) or period (e.g. a 3-year cycle) applies to the specific service/procedure. This does not refer to the number of days spent in hospital or the number of procedures applicable. Private nursing is a service rendered to patients at their home as an alternative to hospitalisation only. Benefits for private nursing are subject to pre-authorisation by Medihelp and exclude general day-to-day services such as bathing and general care. Prescribed Minimum Benefits (PMB) are paid for 26 chronic conditions on the CDL and 270 diagnoses with their treatments as published in the Regulations of the Medical Schemes Act, 1998 (Act No 131 of 1998). In terms of these Regulations, medical schemes are compelled to grant benefits for the diagnosis, treatment and care costs of any of these conditions as well as emergency medical conditions (that meet the published definition) without imposing any limits. PMB are subject to pre-authorisation, protocols, and the utilisation of designated service providers, where applicable, e.g. the SAOC, (or ICON in case of Necesse) for cancer treatment. Pre-authorisation means benefits for a service must be authorised before it is rendered. Per year means from 1 January to 31 December of a year. Should a beneficiary enrol within a financial year, benefit amounts will be pro-rated according to the remaining number of months of the year. All limits are valid for a year unless otherwise indicated. Network benefit options offer benefits to members in collaboration with a medical provider network. Members must make use of the network to qualify for benefits and prevent co-payments. Medihelp Dental Tariff means the benefits for dentistry in accordance with the dental schedule of the Scheme as agreed between Medihelp and Denis. price is determined according to the most cost-effective treatment based on evidence-based principles. The MHRP will differ for the different benefit options and is subject to change (e.g. when new generic equivalents are introduced to the market). Please visit Medihelp’s website at www.medihelp.co.za for the latest MHRP. Members are advised to consult their doctor when using PMB medicine to make sure they use medicine on the MHRP where possible and so prevent or reduce co-payments. Major medical benefits include benefits for hospitalisation, PMB, trauma recovery and benefits that complement care when patients need to recover. Co-payments and sub-limits may be applicable in some cases. A limit is the maximum benefit amount which is paid for a specific service, apparatus or appliance, for example in the case of prostheses. Standard immunisations are child immunisations in accordance with the guidelines set by the Department of Health on the standard immunisation chart. Hospital benefits refer to benefits for services rendered by a hospital during a patient’s stay in hospital. Services include ward accommodation and ward medicine, general radiology and pathology, physiotherapy and other supplementary services rendered during hospitalisation. Hospital benefits are subject to pre-registration and a 20% co-payment will be applicable to the hospital account if the admission is not pre-registered. A 30% co-payment is also applicable to the Dimension Prime Network range should the patient be admitted to a non-network hospital, and a 20% co-payment in the case of Necesse. Emergency admissions must be registered on the first workday following the admission (see also “emergency medical condition”). Procedure-specific co-payments may apply. HIV rapid testing should take place in a controlled clinical environment to determine HIV status and should include pre- and post-testing counselling. This test may be followed by pathology tests according to Scheme protocols. Health-essential functional prostheses necessarily replace a part of the body or a component thereof, or perform an essential function of the body. A formulary can consist of, inter alia, a scientifically compiled list of medicine, e.g. for the treatment of the 26 conditions on the Chronic Diseases List (CDL), or a list of pathology tests or appropriate radiology tests, depending on the discipline. explanation of terms 30 Private nursing, hospice and sub-acute care facilities Tel: 086 0100 678 Fax: 012 336 9523 hmanagement@medihelp.co.za Chronic renal dialysis & oxygen administered at home Tel: 086 0100 678 Fax: 012 336 9540 medihelp@medihelp.co.za Medihelp Customer Care Centre Tel: 086 0100 678 Fax: 012 336 9540 www.medihelp.co.za medihelp@medihelp.co.za Chronic and PMB medicine and more than 30 days’ medicine supply Medihelp Tel: 086 0100 678 Fax: 012 334 2466 (chronic and PMB medicine) Fax: 012 334 2425 (more than 30 days’ supply) medicineapp@medihelp.co.za Prescribed Minimum Benefits (PMB) Medihelp Tel: 086 0100 678 Fax: 012 336 9523 (Necesse) Fax: 086 0064 762 (All other benefit options) necesse@medihelp.co.za (Necesse) pmb@medihelp.co.za (All other benefit options) Medical procedures (not emergencies) obtained abroad Medihelp Tel: 086 0100 678 Fax: 012 336 9540 medihelp@medihelp.co.za HIV/Aids programme (All information will be treated confidentially) OneHealth/Optipharm Tel: 086 0906 090 Emergencies: 083 564 9978 Fax: 086 0064 762 medihelp@optipharm.co.za contact us Medihelp fraudline and compliance department Tel: 012 334 2428 Fax: 012 336 9538 fraud@medihelp.co.za Council for Medical Schemes Tel: 086 1123 267 complaints@medicalschemes.com www.medicalschemes.com Medihelp is an authorised financial services provider MRI and CT scans, prostheses and PMB services (during hospitalisation) Tel: 086 0100 678 Fax: 012 336 9540 medihelp@medihelp.co.za Hospital admissions (All hospital admissions must be pre-registered) Tel: 086 0200 678 Oncology Tel: 086 0100 678 Fax: 086 0064 762 oncology@medihelp.co.za 31
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