Docstoc

2011 Benefit Guide.pdf

Document Sample
2011 Benefit Guide.pdf Powered By Docstoc
					2011 Benefit Guide
Why Choose BESTmed?                                       BESTmed’s Benefit Options is
One of the most important criteria you should             Designed by Members for Members
consider when choosing a medical scheme is its            It is a fact that private healthcare is expensive. At
reserve level. A scheme’s reserve level indicates         BESTmed we understand that very well. That’s why
its ability to pay claims. BESTmed’s reserve ratio is     our benefit options are designed by members for
33.2% - the legal requirement is 25%, a testament         members, who understand that investing in quality
to a Scheme whose risk management is expertly and         healthcare for themselves and their families is
responsibly administered. Other reasons to choose         essential.
BESTmed:
                                                          We want you to be able to select the appropriate
•	 We are a well established Scheme, in operation for     medical cover for you and your loved ones. BESTmed
   more than 46 years.                                    therefore offers a comprehensive range of benefit
•	 We are amongst the top 8 open medical schemes          options that are easy to understand and caters for all
   with a national footprint.                             needs – from the young, healthy and active to those
•	 We have grown in membership base by 11.5%              enjoying their golden years.
   compared to a mere 0.3% industry average.              Please speak to your intermediary to assist you in
•	 We pride ourselves with an incomparable industry       choosing the option that best meets you and your
   expertise and managed healthcare competence.           family’s needs. You can also find more information on
•	 We have been highly rated by ASK Africa for our        BESTmed’s other options on the BESTmed website at
   outstanding service delivery.                          www.bestmed.co.za.

The secret of our success is that what you see is
what you get – there are no hidden costs or fine print.




                                                                                                                   page 1
         The Best Platinum Option is for You, if:                                        An Overview of the Best Platinum
         •	 You require comprehensive day-to-day cover.
                                                                                         Benefits
         •	 You live by the rule ‘prevention is better than                              •	 Comprehensive hospital benefits
            cure’ - you have access to preventative care                                 •	 Chronic medicine for Chronic Disease List (CDL)
            benefits which includes flu vaccines, paediatric                                conditions
            immunisations, oral contraceptives, back
                                                                                         •	 Chronic medicine for non-CDL conditions
            rehabilitation, basic and preventative dentistry, PAP
            smear, mammogram, lipogram, prostate screening                               •	 Preventative care benefits
            test, etc.                                                                   •	 Wellness Management Programmes
         •	 You realise that at any time you might be faced                              •	 International Travel Cover
            with expensive, unforeseen hospital costs.
         •	 You are in need of extensive cover for chronic
            conditions.
         •	 You prefer freedom of choice when it comes to
            visiting a healthcare service provider.

         Contributions

                                               Total contribution


          Principal member                     R3 299
          Adult dependant                      R3 299
          Child dependant*                     R773


         * You only pay for a maximum of four children. All other children can join as beneficiaries on the Scheme free of charge.




page 2
CONTENTS

BENEFIT SUMMARY                         4

  In-Hospital Scheme Benefits           4

  Out-of-Hospital Benefits              6

  Medicine                              7

  Preventative Care Benefits           10

  Wellness Management Programmes       12

  24 Hour Emergency Evacuation         13

  International Travel Cover           13

  Prescribed Minimum Benefits (PMBs)   14


PRE-AUTHORISATION                      15


IMPORTANT ADMINISTRATIVE INFORMATION   15


ONLINE SERVICES                        17


CONTACT DETAILS                        18


GLOSSARY                               19

                                            page 3
                                  BENEFIT SUMMARY

                                  In-Hospital Scheme Benefits
                                  Expenses incurred in hospital will be paid at 100% of the BESTmed tariff. You must obtain an authorisation
                                  number from BESTmed by calling 0800 22 0106. Please refer to page 15 for more details regarding
                                  pre-authorisation.

“Expenses incurred in hospital    Medical event                                                   Scheme benefit

will be paid at 100% of the       Accommodation (hospital stay)                                   100% of BESTmed tariff is paid.
BESTmed tariff. You must obtain   Theatre fees                                                    100% of BESTmed tariff is paid.

an authorisation number from      Take home medicine                                              100% of BESTmed tariff is paid but limited to 7 days’ medicine.

BESTmed by calling                Treatment in mental health clinics                              100% of BESTmed tariff is paid but limited to 21 days per beneficiary.

0800 22 0106. Please refer        Treatment of chemical and substance abuse                       100% of BESTmed tariff is paid but limited to 21 days or
                                                                                                  R16 000 per beneficiary.
to page 15 for more details       Consultations and procedures                                    100% of BESTmed tariff is paid.
regarding pre-authorisation.”     Surgical procedures and anaesthetics for surgical               100% of BESTmed tariff is paid.
                                  procedures and operations
                                  Organ transplants                                               100% of BESTmed tariff is paid.
                                                                                                  Subject to pre-authorisation and protocols.
                                  Maxilla-facial surgery strictly related to certain conditions   100% of BESTmed tariff is paid.
                                  Prosthesis – Internal                                           Paid at 100% of cost but limited to R70 000 per family per year.
                                                                                                  The following sub-limits apply per beneficiary:
                                                                                                  •	   Vascular R25 000
                                                                                                  •	   Spinal R25 000
                                                                                                  •	   Artificial disk R11 000
                                                                                                  •	   Drug eluting stents R11 000
                                                                                                  •	   Mesh R10 000
                                                                                                  •	   Gynaecology/Urology R8 000
                                                                                                  •	   Lens implants R9 000 per lens



 page 4
In-Hospital Scheme Benefits (continued)
Medical event                           Scheme benefit

Prosthesis – External                   Sub-limit of R16 000 per family per prosthesis and condition
                                        per year.
Pathology                               100% of BESTmed tariff is paid.
Radiology                               100% of BESTmed tariff is paid.
MRI and CT scans                        100% of BESTmed tariff is paid.
Oncology                                100% of BESTmed tariff is paid.
                                        Subject to pre-authorisation and registration on the Oncology
                                        Programme.
Peritoneal dialysis and haemodialysis   100% of BESTmed tariff is paid.
                                        Subject to pre-authorisation and protocols.
Confinements                            100% of BESTmed tariff is paid.
Co-payments                             The following co-payments apply:
                                        •	   Shoulder surgery R1 200
                                        •	   Joint replacement (e.g. hip and knee
                                        •	   replacements) R1 200
                                        •	   Laparoscopic nissen R1 200
                                        •	   Spinal surgery R1 200
                                        •	   Hysterectomy R800
                                        •	   Arthroscopy R400




                                                                                                        page 5
                                       Out-of-Hospital Benefits

Out-of-hospital costs will be          Medical event                                          Scheme benefit

paid by BESTmed as per the             GP and Specialist consultations                        Limited to R3 000 for a member and R5 000 for a family.

table below from your overall                                                                 Subject to the overall annual limit.
                                       Basic and specialised dentistry                        Limited to R6 000 for a member and R10 000 for a family.
annual limit, which is R25 000
                                                                                              Subject to the overall annual limit.
for a member and R40 000 for
                                       Medical apparatus                                      Limited to R18 000 per family per year up to the sub-limits of:
a family. Once this overall limit or                                                          •	 Wheelchairs R8 000 per family per 60 months
a sub-limit for a specific benefit                                                            •	 Hearing aids R10 000 per beneficiary per 48 months

has been reached, further out-         Supplementary services such as physiotherapy, speech   Limited to R3 000 for a member and R6 000 for a family.
                                       therapy and occupational therapy                       Subject to the overall annual limit.
of-hospital expenses will be for
                                       Optical benefits                                       Eye test, frames, lenses OR contact lenses are limited to
your own account.                                                                             R3 000 for a member and R5 000 for a family.
                                                                                              Frames are limited to R1 000 per beneficiary per 24 months.
                                                                                              Subject to the overall annual limit.
                                       Radiology and pathology                                Limited to R3 000 for a member and R6 000 for a family.
                                                                                              Subject to the overall annual limit.
                                       Maternity                                              Combined limit – included with GP and Specialist benefit.
                                       Specialised radiology                                  Subject to pre-authorisation.
                                                                                              MRI/CT scans: Maximum of three scans per beneficiary.
                                                                                              PET scan: One scan per beneficiary.
                                       Rehabilitation services after trauma                   100% of BESTmed tariff is paid.
                                                                                              Subject to pre-authorisation and protocols.




  page 6
Medicine

Benefit description                                           Scheme benefit                                                    “The medicine listed in the
**Non-CDL chronic condition medicine                          45 non-CDL conditions are covered at 85% of the BESTmed tariff.   formulary for CDL chronic
Please note that CDL and non-CDL chronic medication costs     Limited to R15 000 for a member and R30 000 for a family.         condition medication will be
will be paid from the non-CDL limit first. Thereafter, CDL    Subject to BESTmed formulary and medicine reference price.
chronic medication costs continue being paid by the Scheme.
                                                              Co-payment of 20% for non-formulary medicines.
                                                                                                                                paid at 100% of the BESTmed
*CDL chronic condition medicine                               100% of BESTmed tariff is paid.
                                                                                                                                tariff, but you must obtain
Please note that CDL and non-CDL chronic medication costs     Subject to BESTmed formulary and medicine reference price.        pre-authorisation for all
will be paid from the non-CDL limit first. Thereafter, CDL    Co-payment of 20% for non-formulary medicines.
chronic medication costs continue being paid by the Scheme.                                                                     prescribed medicine by
Biological medicine                                           Subject to pre-authorisation and limited to R300 000 per          contacting 086 000 2378,
                                                              beneficiary.
                                                                                                                                faxing 012 339 9944 or e-mailing
Acute medicine                                                Limited to R5 000 for a member and R8 000 for a family.
                                                              A 10% co-payment is payable.
                                                                                                                                medicine@bestmed.co.za”
                                                              Subject to overall annual limit and medicine reference price.
Over-the-counter medicine                                     Limited to R1 000 per family per year.
                                                              Subject to the acute medicine limit.


The medicine listed in the formulary for CDL                          South Africa, BESTmed will pay for the generic
chronic condition medication will be paid at 100%                     medicine up to the Mediscor Reference Price (MRP)
of the BESTmed tariff, but you must obtain                            for the active ingredient.
pre-authorisation for all prescribed medicine by
                                                                   •	 The benefit amount for prescribed medicine
contacting 086 000 2378, faxing 012 339 9944 or
                                                                      will be calculated at the Single Exit Price (SEP)
e-mailing medicine@bestmed.co.za.
                                                                      plus the dispensing fee (as determined by
Prescribed medicine will be reimbursed under the                      BESTmed) plus Value Added Tax (VAT), if
following conditions:                                                 applicable.
•	 Where medicines have generic alternatives                       •	 You may be required to obtain your medicine from a
   registered with the Medicines Control Council of                   Designated Service Provider (DSP).

                                                                                                                                                         page 7
         *Chronic medicine for Chronic Disease List (CDL) conditions
         The reference price for medicine listed in the BESTmed formulary for the following 26 chronic conditions will be
         paid provided you obtain pre-authorisation.

         •	 Addison’s Disease                                       •	 Dysrhythmias
         •	 Asthma                                                  •	 Epilepsy
         •	 Bipolar Mood Disorder                                   •	 Glaucoma
         •	 Bronchiectasis                                          •	 Haemophilia
         •	 Cardiac Failure                                         •	 Hyperlipidaemia
         •	 Cardiomyopathy                                          •	 Hypertension
         •	 Chronic Obstructive Pulmonary Disease                   •	 Hypothyroidism
         •	 Chronic Renal Disease                                   •	 Multiple Sclerosis
         •	 Coronary Artery Disease                                 •	 Parkinson’s Disease
         •	 Crohn’s Disease                                         •	 Rheumatoid Arthritis
         •	 Diabetes Insipidus                                      •	 Schizophrenia
         •	 Diabetes Mellitus Type 1                                •	 Systemic Lupus Erythematosus
         •	 Diabetes Mellitus Type 2                                •	 Ulcerative Colitis




page 8
**Chronic medicine for Chronic Disease List (CDL) conditions
The reference price for medicine listed in the BESTmed formulary for the following 45 non-CDL conditions will be
paid at 85% of the BESTmed tariff.

•	 Acne – Severe                                          •	 Idiopathic Thrombocytopenic Pupura
•	 Allergic rhinitis                                      •	 Major depression
•	 Alzheimer’s Disease                                    •	 Migraine prophylaxis
•	 Ankylosing spondylitis                                 •	 Motor Neuron Disease
•	 Aplastic anaemia                                       •	 Muscular dystrophy and inherited myopathies
•	 Attention Deficit Disorder (ADD)/Attention Deficit     •	 Myasthenia Gravis
   Hyperactivity Disorder (ADHD)                          •	 Neuropathy
•	 Benign Prostatic Hypertrophy                           •	 Obsessive Compulsive Disorder
•	 Chronic anaemia                                        •	 Osteoarthritis
•	 Collagen Disease                                       •	 Osteoporosis
•	 Cushing’s Disease                                      •	 Paget’s Disease
•	 Cystic Fibrosis                                        •	 Paraplegia/Quadriplegia (medicine to treat)
•	 Dermatomyositis                                        •	 Polyarteritis nodosa
•	 Eczema                                                 •	 Polycystic Ovarian Disease
•	 Endometriosis                                          •	 Psoriasis
•	 Female menopause                                       •	 Psoriatic arthritis
•	 Fibrosing alveolitis                                   •	 Pulmonary Interstitial Fibrosis
•	 Gastro Oesophageal Reflux Disease                      •	 Pulmonary embolism
•	 Gout prophylaxis                                       •	 Scleroderma
•	 Graves Disease                                         •	 Sjogren’s Disease
•	 Hyperthyroidism                                        •	 Stroke
•	 Hypophyseal adenoma                                    •	 Trigeminal neuralgia
•	 Hypopituitarism                                        •	 Urinary incontinence


                                                                                                                   page 9
                                   Preventative Care Benefits

“Prevention is better than         Benefit type          Gender and age group    Quantity and frequency       Benefit criteria

cure. Pro-active health risk       Influenza vaccine     All ages                One per beneficiary per year Applicable to all active members and beneficiaries.
management is better than          Pneumonia             Children < 2 years      Once in 5 years              Funding for children < 2 years:
                                   Programme             High risk adult group                                Parents to contact BESTmed in advance to pre-
paying for care. Benefits should                                                                              arrange funding prior to obtaining the vaccine.
benefit the member, not the                                                                                   Funding for adults:
                                                                                                              BESTmed will identify certain high risk individuals
disease. Put the health Rand                                                                                  who will be invited to be immunised.

where the health Risk is. Change   Paediatric            Funding for all paediatric vaccines according to the State recommended programme for babies and
                                   immunisations         children.
the course of member claim
                                   Oral contraceptives   All females of child    Monthly fills up to the      Limited to R1 200 per family for the year.
history by changing the health                           bearing age             maximum allowed amount       Includes all items classified in category of oral
                                                                                                              contraceptives.
story of each member.”
                                   Back rehabilitation   All ages                When required                Applicable to beneficiaries that have serious
Dr C du Preez (MD)                 programme                                                                  spinal or back problems and may require surgery.
                                   (provided by                                                               BESTmed identifies appropriate participants
                                   Documentation                                                              for evaluation at the DBC centre. Based on the
                                   Based Care)                                                                outcomes of the evaluation, a rehabilitation
                                                                                                              treatment plan is drawn up and initiated which
                                                                                                              lasts approximately six weeks.
                                   HIB titre             Children 5 years and    One vaccine at 6, 10 and     If the booster vaccine was not administered
                                   immunisation          younger                 14 weeks after birth         timeously, the maximum age to which it will be
                                                                                 1 booster vaccine between    allowed is 5 years.
                                                                                 15-18 months
                                   Mammogram             Females                 Once every 2 years           Must be pre-authorised by BESTmed.
                                                         40-69 years
                                   PAP smear             Females older than      Once per year                To be done at a gynaecologist.
                                                         40 years                                             Gynaecologist claim paid from the consultation
                                                                                                              benefit.



  page 10
Preventative Care Benefits (continued)

Benefit type             Gender and age group    Quantity and frequency        Benefit criteria

PSA test (Prostate       Males older than 50     Once per year
Specific Antigen)        years
Lipogram                 Beneficiaries older     Once per year                 A lipogram is a cholesterol screening test to
                         than 45 years                                         identify beneficiaries at high risk for heart disease.
Bone densitometry        Females older than      Once every two years          Must be pre-authorised by BESTmed.
                         45 years
HIV test                 All ages                One test per beneficiary      One ELISA diagnostic test per beneficiary.
                                                 per year                      Western Blot diagnostic tests excluded from this
                                                                               benefit.

Preventative dentistry

Benefit type                                    Age                                         Frequency

General full mouth examination by a             Above 12 years                              Once a year
general dentist                                 Under 12 years                              Twice a year
Full mouth intra-oral radiographs               All ages                                    Once every 3 years
Intra-oral radiographs                          All ages                                    Two photos per year
Scaling and/or polishing                        All ages                                    Twice a year
Fluoride treatment                              All ages                                    Twice a year
Fissure sealing                                 Up to and including 21 years                In accordance with accepted protocol
Space maintainers                               During primary and mixed denture stage      Once per space




                                                                                                                                        page 11
“Full details of the HIV/AIDS   Wellness Management Programmes                           approved treatment depends on the member’s clinical
                                                                                         results. The stage of the disease and the results of
programme and the benefits      These programmes are aimed at managing your              blood tests determine what treatment will be covered
                                wellbeing and treatment if for example, you:
offered will be provided to                                                              and how the member must be monitored.

members who register. You       •	 Have cancer                                           Full details of this programme and the benefits
                                •	 Are HIV positive or have AIDS                         offered will be provided to members who register.
can also find more on the
                                •	 Are pregnant, etc.                                    You can also find more information on the BESTmed
BESTmed website under                                                                    website under ‘Managed care’ or you can contact
                                You need to register on the relevant programme/s in      011 251 9400.
‘Managed care’ or you can       order to receive the benefits.
contact 011 251 9400.”                                                                   CDL chronic benefit
                                HIV/AIDS benefit management programme
                                                                                         BESTmed’s CDL chronic programme is run by qualified
                                BESTmed covers counselling and testing for members       pharmacists and clinical staff who ensure that
                                who want to confirm their HIV status.                    appropriate, cost-effective and quality treatment is
                                You must be registered on the HIV/AIDS Benefit           provided to members in terms of the Scheme Rules
                                Management Programme in order to receive benefits.       and benefits.
                                Benefits for members, who are HIV positive, cover a      You must apply for the CDL Chronic Benefit if you
                                spectrum of services, including:                         have been diagnosed with a chronic condition and will
                                •	 Advice and counselling from the HIV helpline.         need treatment on an ongoing basis. Please call
                                                                                         086 000 2378 for more information on how to
                                •	 Regular blood tests to monitor disease progression
                                                                                         apply or go to www.bestmed.co.za and click on
                                   and to measure the response to treatment.
                                                                                         ‘Managed care’ and then on ‘Pharmaceutical Benefit
                                •	 Medication and anti-retrovirals (medicine to fight    Management’.
                                   the virus).
                                •	 Where a pregnant mother is HIV positive,              BestBaby
                                   medication is provided to enable her to have
                                                                                         This programme has been designed to support
                                   a natural delivery. Medication (known as post-
                                                                                         pregnant mothers throughout their pregnancy.
                                   exposure prophylaxis) is also given to the new baby
                                                                                         A dedicated 24-hour emergency line with trained
                                   to reduce the chances of infection.
                                                                                         medical personnel can guide members through
                                The treatment programme covered by BESTmed               those sudden and unexpected occurrences during
                                is based on the HIV/AIDS funding guideline and           pregnancy.

  page 12
If a mother is regarded as a clinically high risk, her    24 Hour Emergency Evacuation                                “Full details of the Oncology
pregnancy will be monitored more closely by having
regular blood tests and blood pressure assessments.       This includes emergency transportation by an                Programme and the benefits
                                                          ambulance, response car, helicopter or fixed-wing           offered will be provided to
The programme offers additional benefits such as          aircraft, if for example, you are involved in a motor
free gifts and sonars to all members registered on the    vehicle accident. This service is paid at 100% of the       members who register on
programme.                                                cost if rendered and pre-authorised by ER24.                the programme. You can also
Full details of this programme and the benefits offered
will be provided to members who register. You can also    International Travel Cover                                  find more information on
find more information on the BESTmed website under                                                                    the BESTmed website under
‘Managed care’ or you can contact 011 704 0072.           If you are travelling overseas on holiday, you will enjoy
                                                          the cover provided by the International Travel Cover        ‘Managed care’ or you can
                                                          benefit. Download the policy on www.bestmed.co.za
Oncology benefit management programme                                                                                 contact 012 339 3537.”
                                                          and keep it with you while you are away.
You must be registered on the Oncology Programme
                                                          Note:
in order to receive benefits. Broadly, the programme
offers:                                                   You must contact ER24 on 011 319 6300 to take
                                                          out additional insurance if:
•	 Access to additional benefits and services that
   form part of the treatment protocol.                   •	 You are over the age of 80
•	 Oncology treatment that includes chemotherapy,         •	 You will be travelling overseas for more than 90
   radiation therapy, certain pathology, certain             days
   radiology and certain consultations.                   •	 You will be taking part in hazardous activities while
                                                             you are away
Note:
•	 All services must be pre-authorised by BESTmed.        Emergency medical assistance when travelling
•	 Preferred providers may be appointed by BESTmed.       To access emergency medical assistance when
•	 The services must fall within BESTmed’s funding        you are on holiday internationally, please call
   protocol.                                              +27 010 205 3100. When the operator asks for
                                                          the name or number of your policy, please say ‘ER24
Full details of the Oncology Programme and the            INTERNATIONAL TRAVEL EXTENSION’ and quote
benefits offered will be provided to members who          your BESTmed membership number.
register on the programme. You can also find more
information on the BESTmed website under ‘Managed
care’ or you can contact 012 339 3537.

                                                                                                                                               page 13
          Prescribed Minimum Benefits                                Medical schemes may use certain risk management
                                                                     tools to ensure that cover for PMBs are appropriate
          What is a prescribed minimum benefit?                      and cost effective. Risk management tools used by
                                                                     BESTmed includes:
          Prescribed Minimum Benefits (PMBs) are minimum
          benefits which, by law, must be provided to all medical    •	 Formularies (medicine lists)
          scheme members. This includes the provision of             •	 Clinical funding guidelines and treatment protocols
          diagnosis, treatment and care costs for:                   •	 Pre-authorisation procedures
          •	 A limited set of 270 conditions as specified in         •	 Designated Service Providers (DSPs)
             Annexure A of the Regulations to the Medical
             Schemes Act (No. 131 of 1998).                          When are you eligible for a PMB?
          •	 A list of 26 chronic conditions – also referred to as   BESTmed reimburses a claim as a PMB when a
             the Chronic Disease List (CDL).                         healthcare provider uses the appropriate diagnostic
          •	 Any emergency condition.                                code (ICD-10 code) that corresponds to the published
                                                                     list as per the Council for Medical Schemes. A list of
          What is an emergency?                                      these conditions and codes can be obtained from
                                                                     the Council for Medical Schemes’ website at
          A medical emergency is the sudden, unexpected              www.medicalschemes.com.
          onset of a health condition that needs immediate
          medical or surgical treatment. If the treatment is not     How are PMBs paid?
          provided, then the person’s life would be at risk or
          result in serious impairment or dysfunction of a bodily    BESTmed will cover the diagnosis, treatment
          organ or body part.                                        and costs of PMBs in full, with no co-payment,
                                                                     in accordance with the Scheme Rules, protocols
          BESTmed covers you for in-hospital emergencies. In the     and formularies. The ICD-10 code on the claim
          event of an emergency, you must immediately go to          provides BESTmed with the information to identify
          a hospital for medical care, but remember to obtain an     the treatment/s that should be paid as PMBs. It is
          authorisation number within 48 hours of the consultation   therefore essential that all accounts are submitted
          or on the first working day after the consultation.        with valid ICD-10 codes. This allows us to pay the
          Section 29 of the Medical Schemes Act requires             account from the correct PMB benefit.
          medical schemes to stipulate the scope of minimum
          benefits in its Scheme Rules. Please refer to the
          registered Rules of BESTmed for further details.

page 14
PRE-AUTHORISATION                                           •	 A child older than 21, but not older than 26, who is
                                                               studying and dependent on the member. Proof of
Must I Get Pre-Authorisation?                                  registration to a registered tertiary institution will
                                                               be required.
Yes, before you go into hospital or have any surgery        •	 Immediate family* for whom the member is legally
or diagnostic investigations you must obtain an                liable to provide family care and support.
authorisation number from BESTmed by calling
0800 22 0106.                                               •	 Other persons who are recognised by BESTmed as
                                                               dependants.
In the event of a life-threatening emergency
                                                            * Immediate family refers to the member’s mother, father, brother or
admission after office hours or on weekends or public
                                                            sister. BESTmed will require proof of dependency and a late joiner
holidays, you must obtain an authorisation number on        penalty may apply.
the first working day after the hospital admission. If
you do not pre-authorise a hospital visit, penalties will
                                                            Waiting Periods
be imposed for late authorisation.
                                                            The Medical Schemes Act allows medical schemes
Pre-authorisation is important as it helps to ensure
                                                            such as BESTmed to impose a waiting period on
that you and your service providers are aware of
                                                            benefits under certain circumstances. This means
what expenses will be paid by BESTmed. The pre-
                                                            that you will not be able to access a particular benefit
authorisation process includes the management of
                                                            for a specified period of time.
your stay and treatment in hospital.
                                                            There are two types of waiting periods:
For more information on pre-authorisation, please go
to www.bestmed.co.za and click on ‘Managed care’            •	 Condition-specific waiting period – this refers
and then on ‘Hospital Benefit Management’.                     to a specified period of time during which a
                                                               beneficiary cannot claim benefits for a condition
IMPORTANT ADMINISTRATIVE                                       for which medical advice, diagnosis, care or
                                                               treatment was recommended or received within
INFORMATION
                                                               the twelve-month period before the member
                                                               applied to join BESTmed.
Who Can Be a Dependant?
                                                            •	 General waiting period – this is a specified period
BESTmed recognises the following people as                     of time during which a beneficiary is not entitled to
dependants:                                                    claim any benefits.
•	 The member’s spouse or partner.                          If you are on chronic medication, you may be able to
•	 A child older than 21 if the child is dependent on       claim for certain treatments or chronic medication
   the member due to a mental or physical disability.       covered under the Prescribed Minimum Benefits.

                                                                                                                                   page 15
                                However, if you were not a member or dependant of         How to Submit a Claim
                                a registered medical scheme for longer than 90 days
                                before joining BESTmed, you will not be able to claim     Please submit the original claim directly to BESTmed
                                for certain treatments or chronic medication covered      if your service provider does not submit claims. Make
                                under the Prescribed Minimum Benefits.                    sure that your personal details, membership number
                                                                                          and claiming details are correct before submitting the
                                                                                          account.
                                Pro-Rata Benefits
                                                                                          •	 The following details must appear on all claims:
                                BESTmed benefits are calculated for a period of 12
“Claims can be scanned and      months from 1 January to 31 December. If a member         •	 Name and contact details of member
e-mailed to                     joins during the year, e.g. in May, the benefits can      •	 BESTmed membership number
                                be calculated according to the number of months           •	 Name and contact details as well as practice
register@bestmed.co.za or       remaining in the year.                                       number of the service provider
posted to BESTmed Medical                                                                 •	 Details of treatment, including applicable tariff and
Scheme, PO Box 2297, Arcadia,   Late Joiner Penalty                                          ICD-10 codes

Pretoria, 0001.”                Late joiner penalties can be imposed on new members       •	 Details of patient
                                over the age of 35. Depending on the number of years      •	 Whether to pay the service provider or the member
                                where the member did not belong to a medical scheme,
                                a late joiner penalty will be added to the member’s       Claims can be scanned and e-mailed to
                                monthly contribution. The penalty is calculated on a      register@bestmed.co.za or posted to BESTmed
                                sliding scale as shown in the table below, based on the   Medical Scheme, PO Box 2297, Arcadia, Pretoria, 0001.
                                total number of years from age 35 where a member did      You must submit the claim, with the necessary proof
                                not belong to a medical scheme.                           of payment, within four months of the treatment. If
                                                                                          your claim was not received within four months, your
                                Number of years since                                     claim will be rejected and you will have to settle the
                                age 35 where applicant
                                was not a member of a
                                                           Penalty                        account yourself.
                                medical scheme
                                                                                          Claims are processed within 48 hours of receipt.
                                1 – 4 years                1.05 x contribution            BESTmed has a claims payment run every Friday as
                                5 – 14 years               1.25 x contribution            well as a month-end payment run (three working days
                                                                                          after the last day of the previous month).
                                15 – 24 years              1.5 x contribution
                                                                                          Money will be paid directly into your bank account
                                25+ years                  1.75 x contribution
                                                                                          within seven working days of receipt of your claim.

 page 16
Please remember to attach your proof of payment          The online service provides you with access to your:
and that it is your responsibility to ensure that
                                                         •	 Personal details
BESTmed has your updated bank account details.
                                                         •	 Claims history
You will receive a mini statement via e-mail notifying   •	 Process status of submitted claims
you the day after a claim was processed of the status
                                                         •	 Benefits available
of the claim - you can reply to the e-mail if you have
any queries regarding the claim/s.                       •	 Contributions paid

A complete claims statement (remittance advice)
                                                         Webmail Facility
is sent to you via e-mail or post after each claims
payment run. Please ensure that the details on the       For a summary of your chronic medicine and
statement are correct.                                   condition/s as registered, personal details and the
                                                         three most recent claims received and assessed, just
                                                         send a blank e-mail to webmail@bestmed.co.za
ONLINE SERVICES                                          and you will receive the information via e-mail from
                                                         us. Please ensure that BESTmed has your correct
How To Register Online                                   e-mail address.
•	 Go to www.bestmed.co.za
                                                         SMS SERVICE
•	 Click on ‘Online services’
•	 Click on the ‘Register’ link                          If you’d like to receive your BESTmed information
                                                         directly to your cell phone, depending on the
•	 Fill in the details as requested                      information you require, SMS either A, B or C to 31416.
•	 Click on ‘Complete’
                                                         A = Personal details
•	 You will receive an activation process form           B = Summary of benefits available
•	 Please print, sign and fax the form to                C = Confirmation of three most recent claims
   012 339 9900

We will then activate your password when we
receive your fax and will notify you via e-mail once
this has been done. The next time you go to ‘Online
services’ you will be able to login using your BESTmed
membership number.

                                                                                                                   page 17
CONTACT DETAILS

General                                                  CDL Chronic Medication                      Website Technical Issues
Tel:        086 000 2378                                 Tel:      086 000 2378
                                                                                                     e-mail:   webmaster@bestmed.co.za
e-mail:     service@bestmed.co.za                        e-mail:   medicine@bestmed.co.za
Fax:        012 323 4106                                 Fax:      012 339 9944
                                                                                                     Regional SHDS Offices
Walk-in Facility                                         ER 24 and International Travel Cover        Sanlam Healthcare Distribution Services (SHDS) is the
551 Belvedere Street, Arcadia, Pretoria                  084 124                                     marketing and distribution network of BESTmed.


Postal Address                                           BestBaby                                    Gauteng                   080 028 7633
PO Box 2297, Arcadia, Pretoria 0001                      Tel:      011 704 0072                      Free State                086 010 5153
                                                         e-mail:   service@bestmed.co.za             Western Cape              086 010 5154
                                                                                                     Port Elizabeth            086 010 4950
Claims
                                                         HIV/AIDS Programme                          East London/Mthatha       086 010 4950
Tel:        086 000 2378
                                                                                                     KwaZulu-Natal             086 010 9920
e-mail:     service@bestmed.co.za (queries)              Tel:      011 251 9400
            register@bestmed.co.za (claim submissions)   e-mail:   bestmed@optipharm.co.za           Mpumalanga                086 010 4950
                                                                   mhc@bestmed.co.za                 Limpopo                   086 099 9633
Hospital Authorisation                                   Fax:      086 500 9822
Tel:        0800 22 0106
                                                                                                     BESTmed is administered by Sanlam, one of
e-mail:     authorisations@bestmed.co.za
                                                         Oncology Programme                          South Africa’s leading financial services groups,
                                                         Tel:      012 339 3537                      with an enviable track record of providing
                                                         e-mail:   diseasemanagement@bestmed.co.za   products and services that embody their values
                                                                                                     of trust, honesty, integrity and caring. Like
                                                         Online Service Access and Queries           Sanlam, BESTmed continually strives to offer the
                                                                                                     best with value-for-money products supported
                                                         e-mail:   service@bestmed.co.za
                                                                                                     by superior client service to make your dealings
                                                                                                     with BESTmed efficient and to your satisfaction.
                                                         Webmail (e-mail facility)
                                                         e-mail:   webmail@bestmed.co.za



          page 18
GLOSSARY
BESTmed dispensing fee              The fee a pharmacist charges for dispensing medicine.
BESTmed tariff                      The price paid by BESTmed for a medical service provided.
Biological medicine                 Biological medicine is medicine that is derived from living sources, e.g. insulin
                                    and growth hormones.
Chronic Disease List (CDL)          A CDL is a list of chronic conditions where BESTmed will provide and pay for
                                    medication and the treatment of the chronic condition. Refer to page 8 for the list.
Co-payment                          This is the portion of the total cost of a procedure or consultation that you must
                                    pay directly to the service provider or, you may request it to be paid from the
                                    available funds in your medical savings account.
Designated Service Provider (DSP)   A regulated healthcare provider (facility or State operated service provider)
                                    contracted by the Scheme to provide diagnosis, treatment and care in respect of
                                    one or more conditions, to its members.
Formulary                           A formulary is a list of medicines that BESTmed will pay for to treat the chronic
                                    conditions as per the option you have selected.
Maxilla-facial surgery              Surgery to the jaw or jawbone.
Medical savings account             Medical expenses are paid from your medical savings account, as stipulated per
                                    your selected option. When your medical savings account has been exhausted,
                                    you will pay for out-of-hospital expenses yourself. Any unused funds in your
                                    medical savings account at the end of a benefit year will be carried over to the
                                    next year. Should you resign from the Scheme in the duration of a benefit year,
                                    the funds in your medical savings account will be paid back to you after a period
                                    of four months.
Mediscor Reference Price (MRP)      The MRP is a reference list of generic medicines that cost less than original
                                    brand name products. MRP sets a maximum reimbursement price for each
                                    generic product. This list is reviewed regularly to ensure that a comprehensive
                                    range of affordable medicine is available. A change in the MRP will affect the
                                    co-payment amount.
Non-CDL condition                   There are other chronic conditions which do not form part of the CDL.
                                    Depending on the option you select, BESTmed may pay part or all of the
                                    treatment cost.
Pre-authorisation                   Giving approval for a medical event before it occurs.


                                                                                                                           page 19
          GLOSSARY (continued)
          Prescribed Minimum Benefit (PMB)   A PMB is a benefit which, by law, must be provided by BESTmed to all its
                                             members. This includes diagnosis, treatment and ongoing care costs.
          Prosthesis                         An artificial part supplied to remedy a deficiency, e.g. leg, arm, etc.
          Protocols                          Protocols are clinical guidelines, compiled by experts in the field of a specific
                                             medical condition, which specify how a condition should be treated based on
                                             best practice principles.
          Single Exit Price (SEP)            SEP refers to legislation mandating that medicine manufacturers may only sell
                                             their products at one price to all their customers, regardless of the nature of
                                             the customer’s order size and consumption levels. The term means that each
                                             and every product and its variants ‘exits’ the factory at one single price for that
                                             product or variant.
          Specialised dentistry              It is special dental procedures including root canals, gum surgery, oral surgery
                                             and implants.
          Supplementary services             This includes services rendered by dieticians, chiropractors and homeopaths
                                             and for services including acupuncture, speech therapy, audiology, occupational
                                             therapy, physiotherapy, etc.




page 20
    BM44 11/2010
01/BESTPLAT/2011




 Disclaimer: Whilst BESTmed has taken all reasonable care in
 compiling this benefit guide, we cannot accept liability for any
 errors or omissions contained herein. Please note that should a
 dispute arise with regard to any benefit, the registered Rules
 of BESTmed as approved by the Registrar of Medical Schemes
 shall prevail. The Scheme’s Rules is pending the Registrar’s approval.
 www.bestmed.co.za

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:7/16/2012
language:English
pages:22