| ENSURING SUSTAINABILITY FOR 2010 AND ONWARDS |
It's that time of the year again where all medical schemes are announcing their rates and benefits for 2010. We are using this edition of HouseCall! to supply you with all your rates and benefits information for 2010. This means that you will not receive a confirmation pack in the post. However, all the information you need is right here in this issue, so please keep it in a safe place as you may want to refer to it during the year for benefit, administration and contact information.
This year was indeed one of the toughest years in determining benefits and rates for the coming year. Unfortunately, the economic pressures experienced by the country as a whole did not escape the medical aid industry. Besides this, a high-claiming pattern during the current year and a higher than expected increase in the National Health Reference Price List (NHRPL) and Single Exit Price (SEP) added to the pressure. Our philosophy of Real Medical Aid and to be there when our members need us most is always the main consideration when this important topic is deliberated upon. The normal juggling between benefit reductions and contribution increases was therefore all the more difficult this year.
We are once again satisfied that our philosophy prevailed when final decisions were made. We have opted for a slightly higher increase while maintaining most of our core benefits. While we had to reduce the reimbursement rate of 300% on our lower options, we believe that by maintaining 300% in the case of certain procedures required as a result of accident and injury as well as for normal maternity deliveries, we are maintaining our promise to members to be there when they need us most. This will ensure sustainability of the scheme for 2010 and beyond.
All day-to-day benefits (OHEB and Savings), benefit limits and Safety Net Levels will remain unchanged for 2010. However, a 20% co-payment has been introduced on our lower options for all claims paid from the Safety Net Benefit.
We are proud to announce that we have been able to retain all the unique benefits the scheme has become known for and our members accustomed to. Fedhealth remains the scheme who pays for more benefits from risk than any other scheme in the market. We are also pleased to announce that the scheme is healthy and continues to grow. We have maintained our AA- Global Credit Rating which confirms our claims paying ability and fourteen thousand new members signed up for Real Medical Aid so far this year, bringing our net membership to 87 239 as at 31 August.
On a few occasions during the year we have stressed the importance of being on the correct option. This is now the time for our members to consider their option for 2010. If you are satisfied with your current option, you are not required to do anything to confirm your option for 2010. You will automatically have access to the 2010 benefits as from 1 January 2010.
However, if your circumstances have changed, for example marriage, a new baby or a diagnosis of a serious illness in the family, and your current option no longer serves your needs, now is the time to upgrade. To do this, you need to complete an option selection form which can be obtained at www.fedhealth.co.za or by calling our call centre on 0860 002 153. Completed option selection forms must then be faxed to 011 671 3647 or scanned and e-mailed to update@fedhealth.co.za or mailed to Product Renewal 2010, Private Bag X3045, Randburg, 2125 before 30 November 2009.
In the rest of this issue of HouseCall! you will find pricing and benefit structures and calculations based on specific family configurations. Please take the time to go through these benefit schedules. Call our call centre 0860 002 153 should you require assistance.
We would like to thank you for your continued support. We trust that you will continue to enjoy the benefits of Real Medical Aid together with the predicted economic upswing and the FIFA World Cup in 2010.
Regards
Peter Jordaan
Acting Principal Officer |
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HOW DOES YOUR SCHEME WORK |
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In-Hospital Benefit
All costs for hospitalisation are covered from this benefit.
Chronic Disease Benefit
Your medication for approved chronic diseases is covered from this benefit.
Day-to-Day Benefit
Your day-to-day expenses are covered from the Out-of-Hospital Expenses Benefit (OHEB) and Savings, up to cost.
Safety Net Benefit
The Safety Net Benefit pays for certain day-to-day expenses once your OHEB and Savings have been depleted and your claims have accumulated to the required level. |
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RISK BENEFITS
In-Hospital Benefit
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All authorised costs for hospitalisation are covered from this benefit at private rates. |
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Hospital costs will be covered unlimited from this benefit except for certain interventions which are based on case management protocols. These protocols have been introduced to ensure best quality treatment at best rates. Consult the In-Hospital Benefit table above for detail on these interventions and their limits. |
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Selected procedures performed in a day ward, day clinic and the doctor's rooms are also covered from this benefit and not from your day-to-day benefits. For a list of these procedures please phone the Fedhealth Customer Call Centre on 0860 002 153 or visit the Fedhealth website on www.fedhealth.co.za |
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Specialised Radiology, for example MRI and CT scans, are also covered from the In-Hospital Benefit whether the procedure is performed in hospital or not. Specialised Radiology will therefore be paid by the scheme and will not be deducted from OHEB or your Savings. (Needs to be pre-authorised.) |
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Treatment received in a casualty ward for trauma as well as any other treatment in a casualty ward immediately followed by a hospital admission is covered from the In-Hospital Benefit. Trauma is defined as a physical injury to the body by an external force which requires immediate attention, for example stitches. |
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Certain treatment arising from a hospital event, for example physiotherapy, x-rays and blood tests, are covered for 30 days from date of discharge from the In-Hospital Benefit.
For a list of these treatments please phone the Fedhealth Customer Call Centre on 0860 002 153 or visit the Fedhealth website on www.fedhealth.co.za |
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All costs covered by the In-Hospital Benefit need to be pre-authorised by the Authorisation Centre on 0860 103 951. |
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The Chronic Disease Benefit covers 56 chronic conditions listed in the benefit table, which includes the 25 Prescribed Minimum Benefit (PMB) conditions. Consult the Chronic Disease Benefits table above for a list of these conditions and your applicable limits. |
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Formularies & DSP: The scheme makes use of formularies and a Designated Service Provider (DSP) to manage the cost and ensure accessibility and appropriate level of care for all our members. |
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Formularies: A formulary is an approved list of medication for each of the chronic conditions covered by the scheme. These formularies in no way compromise the quality of healthcare that you, the member, receives. Formularies are also subject to the MPL. Please see table above for option specific detail. |
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DSP: Fedhealth's Designated Service Provider (DSP) is the MEDI-Rite group of pharmacies, located in Shoprite supermarkets. Use of the DSP is dependent on your option choice. Please see table above for option specific detail. |
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Co-payments: If your option requires you to use Fedhealth's DSP (MEDI-Rite pharmacies), or is subject to one of Fedhealth's formularies, and you choose to rather use a service provider of your choice or out-of-formulary medication, please note that this will attract a 40% co-payment. If this is in respect of a PMB condition, then the co-payment is not refundable from savings. |
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Medicine Price List (MPL): Your medication will be covered at Medicine Price List (MPL) rates up to the limits as specified in your option. MPL is a reference price list that benchmarks each product against generically similar products. It does not restrict member's choice, but limits the amount that the scheme will refund for each product. The MPL reference price is set at a level to ensure that a number of medicines will be available without any co-payment. |
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Treatment Guidelines: The scheme has established treatment guidelines for the 25 PMB conditions to ensure that you receive appropriate treatment for your condition. You will receive details of the treatment guidelines applicable to you once you register for one of these conditions. |
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How to apply: On diagnosis of a listed chronic condition you and your doctor will need to complete an application form which is obtainable from the Fedhealth Customer Call Centre on 0860 002 153, the Fedhealth website www.fedhealth.co.za or directly from Chronic Medicine Management (CMM) on 0860 100 608. Your doctor can fax this completed form to CMM on 0800 223 670/ 80 for approval. CMM will review your application and liaise with your doctor if necessary. |
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Once your application has been approved: CMM will provide you with your medicine access card which will list the approved medicines to be covered from this benefit. Once you have received your medicine access card, your doctor will need to provide you with a repeat prescription for a maximum of six months (legislative requirement) for the approved medicines. |
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What to do if your authorised chronic medication changes: If the doctor decides to change your medication, CMM needs to be advised. The quickest and simplest way would be for your doctor to inform CMM telephonically on 0860 100 608. Within 24 hours, a temporary medicine access card will be faxed to your pharmacy enabling them to dispense your medicine without delay. Alternatively, your new prescription can be faxed to CMM on 0800 223 670/ 80 and your request will be processed within five working days. Your new medicine access card will be mailed to you. Make sure your doctor provides you with an updated repeat prescription to match the approved medicines on your medicine access card. |
Fedhealth offers Disease Management Programmes that support specific diseases. These programmes are offered at no additional cost.
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AID FOR AIDS (AFA)
AfA is a comprehensive HIV disease management programme with access to anti-retrovirals and related medicines as well as post-exposure preventative medication. Ongoing patient and provider support as well as regular monitoring of disease progression and response to therapy is provided. To join AfA call them in confidence on 0860 100 646. Your doctor may also call AfA on your behalf. |
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ASTHMACARE
Most people with asthma should be able to enjoy a normal lifestyle, including getting a good night's sleep and being able to participate in sport and other normal daily activities. AsthmaCare enables you to achieve this by focusing on the appropriate use of medicine. The programme also provides education and counselling on issues that will help you to clearly understand and manage the disease. Phone 0860 101 306 or e-mail diseasemanagement@medscheme.co.za for more detail or to register. |
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CARDIOCARE
Anyone who has had angina or a heart attack is well aware of how important good medicine management is and how critical it is to tackle any lifestyle risks you may have. CardioCare focuses on members who have coronary heart disease, with the aim of preventing heart attacks. The programme promotes healthy lifestyle and the appropriate monitoring and treatment of risk factors. Phone 0860 101 306 or e-mail diseasemanagement@medscheme.co.za for more detail or to register. |
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CENTRE FOR DIABETES AND ENDOCRINOLOGY (CDE)
Only available on Maxima Plus
This programme offers you support to manage your diabetes and focuses on preventative measures such as diet, exercise and regular check-ups with specialists as well as medication and monitoring devices. To register on the programme, call (011) 712 6000 or e-mail cdecentr@iafrica.com |
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DIABETICCARE
This programme helps you to control your blood sugar. It also addresses the importance of screening tests and the necessity of lifestyle adjustments, which can vastly improve the well being of diabetic patients. The programme also educates you on correct medicine management and monitoring. Phone 0860 101 306 or e-mail diseasemanagement@medscheme.co.za for more detail or to register. |
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ONCOLOGY DISEASE MANAGEMENT PROGRAMME (ODM)
On diagnosis of cancer, it is important that you register on the Oncology Disease Management Programme (ODM). Call them on 0860 100 572. The programme assists your doctor to ensure best treatment and support. Your oncology benefit (refer to the In-Hospital Benefit table above) covers the following expenses: chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology. Specialised radiology, for example MRI and CT scans, will be covered from the unlimited In-Hospital Benefit and will not affect your oncology benefit limit. |
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DAY-TO-DAY BENEFIT
OUT-OF-HOSPITAL EXPENSES BENEFIT (OHEB) AND SAVINGS
OHEB is not available on Maxima Core
Savings is not available on Maxima Basis
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Day-to-day expenses such as visits to your GP and dentist and medication are covered from available funds in your Out-of-Hospital Expenses Benefit (OHEB) and Savings Account. To calculate your benefit amount for the year refer to the rate table for your applicable option above. Should you join after the 1st of January, these benefit amounts for the year will be calculated on a pro-rata basis. |
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Your day-to-day benefit limit is the total of OHEB and Savings available. Sub-limits will apply for claims refunded from OHEB and for accumulation to Safety Net. |
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Day-to-day expenses will be refunded from OHEB first at NHRPL tariffs and MPL rates and when it is depleted, from your Savings Account up to cost. Should claims refunded from OHEB be in excess of the allowed tariffs, the balance will be refunded from Savings. |
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Over-the-counter medication (schedule 0, 1 and 2) will not be refunded from OHEB except on Maxima Basis, but will be refunded from Savings. |
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Year-end Savings Account balances will be carried over to the new year. Should you resign from the scheme, any balances will be transferred to your new scheme. Amounts owing to the scheme are payable to the scheme on resignation. |
SAFETY NET BENEFIT
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The Safety Net Benefit pays for day-to-day expenses once OHEB and Savings have been depleted and your claims have accumulated up to the required level. To calculate your Safety Net Level, refer to the rate table for your applicable option above. |
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Your Safety Net Level is reached through the accumulation of your claims paid from OHEB and Savings and your own pocket through the year at MPL rates and NHRPL tariffs. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Safety Net. However, further claims will be paid if Savings are available. Consult the day-to-day benefit table above on your applicable option for detail on these accumulation limits. |
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It may happen that your OHEB and Savings have been depleted before the required Safety Net Level has been reached. This is referred to as a self-payment gap. You will now continue to pay for day-to-day expenses from your own pocket. In order to close this self-payment gap, you need to continue to submit these expenses to Fedhealth. These claims will not be refunded, but will accumulate towards your Safety Net Level. (Please refer to previous point for detail on accumulation limits). |
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Once you have reached the required Safety Net Level, your day-to-day expenses will now be refunded from the Safety Net Benefit. Most of your day-to-day expenses will be covered unlimited except for advanced dentistry, optometry, prescribed medication and appliances for which only the remainder of the annual limit will apply. For example, if a family spends R7 000 on optometry, a maximum of R6 560 (set sub-limit) will accumulate to their Safety Net Level. Once this family is in Safety Net, they will have no further optometry benefit. |
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EMERGENCY MEDICAL SERVICES
As a Fedhealth member, you can contact Europ Assistance for a range of emergency services on 0860 333 432. These services include:
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Emergency road or air response |
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Medical advice in any emergency situation |
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Delivery of medication and blood |
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Patient monitoring |
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Care for stranded minors or frail companions |
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24-hour personal health adviser. |
PROFESSIONAL SPORTS AND HAZARDOUS PURSUITS
Fedhealth is one of the few schemes that offers full cover to people who partake in professional, adventurous and even extreme sports, for example scuba diving, skydiving, bungee jumping, hunting and mountaineering.
FEDHEALTH BABY
The Fedhealth Baby programme has been put together by experts with you and baby in mind. From great give-aways, discounts and education to just plain fun, you'll find that the Fedhealth Baby programme is there to make your experience all the more special.
We offer the following benefits:
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A Fedhealth Baby bag packed to the brim with quality products; from all the Pigeon Baby care products you'll ever need, to nappies and, "Having your Baby" Handbook and more! All especially chosen to take care of your little one from top to toe |
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Discounts for the best baby brands including Huggies, Chelinos, Living & Loving, Preggie Bellies and a whole lot more |
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On-going communication and education in the form of e-mails (to mum and dad!) and e-letters |
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Health profiling for each trimester |
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Monthly call-outs to high risk members |
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E-mail registration for chronic risk communications |
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24hour Medical Advice Line |
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New birth card. |
In addition, a Fedhealth Baby representative will maintain contact over each trimester to make sure that mother and baby are making healthy progress. Any Fedhealth member or dependant who is pregnant can register on the Fedhealth Baby programme at no additional cost by calling them on 0861 116 016.
DISEASE MANAGEMENT PROGRAMMES
Fedhealth believes in holistic treatment for members suffering from serious diseases such as diabetes, AIDS and cancer by providing various management programmes.
WORKING IN AFRICA
Medical evacuation for South African contract workers exporting their skills to Africa.
TRAUMA COUNSELLING
After a traumatic experience, for example falling victim to crime or a motor vehicle accident, Fedhealth provides emotional and practical support through ICAS. Call them on 0800 212 695. |
| USER TIPS |
PRE-AUTHORISATION
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You need authorisation for any benefit payable from the In-Hospital Benefit, for example, a planned or emergency hospital admission, specialised radiology, selected procedures, 30-day post-hospitalisation benefit and casualty ward treatment. |
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The Authorisation Centre needs to be contacted at least 48 hours before admission for a non-emergency or planned procedure to obtain an authorisation number. |
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In an emergency, or if you need to be admitted sooner than planned, you must obtain an authorisation number from the Authorisation Centre within two working days after admission. |
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If you are unable to contact the Authorisation Centre yourself, then your doctor or a family member or the hospital can contact us on your behalf. |
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We need the following information to authorise your treatment: |
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~ Membership number |
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~ Member or beneficiary date of birth |
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~ Reason for admission and applicable tariff codes for the proposed treatment |
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~ Date of admission and the proposed date of operation |
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~ The doctor's name and his/ her telephone and practice numbers, if available |
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~ Name of the hospital with telephone and practice numbers, if available |
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~ For a CT scan, MRI procedure, etc., the name of the radiological practice is also required. |
Contact number: 0860 103 951
(Monday to Friday 08h00 - 17h00)
Fax number: 0860 212 223
E-mail: authorisations.cpt@medscheme.co.za
HOW TO CLAIM
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In most cases your healthcare professional will submit your claim on your behalf directly to Fedhealth via Electronic Data Interchange (EDI). In this case, please do not also submit this claim. |
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If the healthcare professional does not submit a claim on your behalf, or if you have settled the account yourself, all you need to do is sign the account from the healthcare professional indicating proof of payment and your membership number. Forward this to Fedhealth either by mail, fax or e-mail for fast and effective processing. |
Postal address: Private Bag X3045
Randburg
2125
Fax number: (011) 671 3842
E-mail: fedhealth@medscheme.co.za
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Should your healthcare professional inform you that the claim has not been paid, you can contact the Fedhealth Customer Call Centre to enquire on the status of the claim on 0860 002 153. |
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If you have paid the healthcare professional, Fedhealth will refund you directly into your bank account. |
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ICD-10 coding: It's important to remember that all claims to a medical scheme must contain the correct ICD-10 code. Claims not containing the correct code will be rejected. |
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As Fedhealth no longer issues cheques, please ensure that the scheme is in possession of your updated banking details for refund purposes. To update your banking details, please phone the Fedhealth Customer Call Centre on 0860 002 153. |
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Only claims received within 4 months of treatment will be processed. |
CLAIMS AGAINST THE ROAD ACCIDENT FUND
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If you have been involved in a car accident, you may have a claim against the Road Accident Fund. |
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Certain procedures will apply before claims will be paid by the scheme. |
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Please contact the MVA Third Party Recovery Department for further details. |
Telephone number: (011) 669 3166/ 7/ 9
Fax number: (011) 669 2646
Postal address: P O Box 781692, Sandton, 2146
WHO CAN BE REGISTERED AS A DEPENDANT?
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Your spouse, partner, children or other family members who rely on you for financial care and support may be registered as your dependants. |
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Fedhealth will charge the child rate for your child dependants until they turn 27. However, the child needs to be a full-time student, either living at home or in a residential situation at a tertiary education institution. If your child is not a student, Fedhealth needs confirmation that they are living at home, unmarried, and not in receipt of a regular income greater than the maximum social pension. |
ELECTRONIC COMMUNICATION SERVICES
Managing your medical aid fast and effectively
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Real-time electronic communication
Fedhealth will e-mail and SMS a claim status to you showing claims that have been processed. Please ensure that Fedhealth has your correct cell number and e-mail address by calling the Fedhealth Customer Call Centre on 0860 002 153. |
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Website
You can also view a full update of your benefit and claim status by registering on the Fedhealth website. You will have immediate access to all your personal information. Fedhealth website: www.fedhealth.co.za |
CREDIT CONTROL
Contributions to Fedhealth are paid monthly in arrears and should be received by the scheme by the 3rd of the following month.
FEDHEALTH'S BANKING DETAILS
Account name: Fedhealth Medical Scheme
Bank: Nedbank
Branch code: 19-84-05
Account number: 1984 563 009
LEAVING THE SCHEME
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Should you wish to resign from Fedhealth, we require three month's written notice. |
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Any balance in your Savings Account is paid out to you or transferred to your new medical scheme's savings account, five months after you have left Fedhealth. This ensures that all outstanding claims have been received and processed. If there is a balance owing to the scheme, this must be repaid to Fedhealth on resignation. |
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Please note that as Fedhealth is an arrears scheme, your last contribution will be deducted by the 3rd of the month following your last day of membership. |
FRAUD MANAGEMENT
You can help combat fraud by anonymously contacting our fraud hotline if you become aware of any healthcare professional or member abusing the system. Fraud Hotline: 0800 112 811 |
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This summary is for information purposes only and does not supersede the Rules of the Scheme. In the event of any discrepancy between the summary and the Rules, the Rules will prevail. A copy of the Rules is available on request.
Disease Management
Monday to Friday 08h00-16h00
Tel: 0860 101 306
e-mail: diseasemanagement@medscheme.co.za
Web: www.medscheme.co.za
Fedhealth Baby
Monday to Friday 08h00-17h00
Tel: 0861 116 016
e-mail: info@babyhealth.co.za
Web: www.babyhealth.co.za
Fraud Hotline
Tel: 0800 112 811
ICAS (Trauma Counselling)
Tel: 0800 212 695
MVA Third Party Recovery Department
Monday to Friday 08h00-16h00
Tel: (011) 669 3166/ 7/ 9
Fax: (011) 669 2646
Postal address: MVA Third Party Recovery Department
P O Box 781692, Sandton, 2146
Oncology Disease Management
Monday to Friday 08h00-16h00
Tel: 0860 100 572
Fax: (021) 514 2303
e-mail: cancerinfo@medscheme.co.za
Web: www.medscheme.co.za
Postal address: P O Box 38632, Pinelands, 7430 |
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