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BPSA Medical Aid Society

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									BPSA Medical Aid Society


    2004 Benefit Structure
            December 2003


      Andrew Mestern    Chairman
   Cheryl Robertson Principal Officer
   Lorraine Davies   Scheme Manager
Agenda

• How the Medical Aid Works
• Why the BPSA Medical Aid?
• Ways of Saving Costs
• Member Demands
• Factors driving costs upward in 2004
• Meeting demands
• Other Benefit Changes
• Costs for 2004 vs 2003
How the Society Works


                         Investment
                         Returns/Interest

 Member                                         BP
Contributes
                  BPSA                      Contributes
                 Medical
                   Aid
                 Society




                Benefits &
                Expenses
How the Society Works



If benefit                                 Contributions
payments                                   must also go
go up                                      up




             ……. to keep the scale in balance
Why the BPSA Medical Aid

• Condition of Service
• Good risk pool
• Reduced administration fees
• Non-profit
• Control over benefit structure and contribution increases
• Control over reserves
• BPSA sponsors the Society
• BPSA Management & Expertise
• BPSA Governance Assurance
Cost Saving Initiatives
 Method                                bp

 Co-payments                           

 Benefit Limits                        

 Disease Management                     HIV/AIDS

 Medicine Management                   

 Hospital Pre-authorisation            

 Generics (MMAP)                       

 Formulary (List of approved chronic   X (To be introduced)
 medicines)
 Networks (Preferred Provider &        X (To be introduced)
 Designated Service Provider)
 Savings Accounts                      X (Not feasible)

 Capitation Arrangements               
Factors driving costs upward in 2004

• Medical Inflation


• Medical costs to increase by more than consumer inflation
  (CPI).
• Without benefit improvements:
           - in-hospital expenses to go up by 10% next year,
           - out-of-hospital costs to increase by 8%, and
           - chronic medication to go up by 12%.
Factors driving costs upward in 2004

• Increase in average age


• Average age of our members increases each year
• Medical expenses increase with age
• This adds 3% to the cost of providing benefits
Factors driving costs upward in 2004
Prescribed Minimum Benefits: PMB CDL Conditions
• From 1 January 2004
• Pay for treatment of 25 chronic medical conditions:
•   Addison’s Disease                     Asthma                          Bronchiectasis
•   Cardiac Failure                       Cardiomyopathy                  Chronic Renal Disease
•   Chronic Obstructive Pulmonary Disease Coronary Artery Disease         Crohn’s Disease
•   Diabetes Insipidus                    Diabetes Mellitus Types 1 & 2   Dysrhythmias
•   Epilepsy                              Glaucoma                        Haemophilia
•   Hyperlipidaemia                       Hypertension                    Hypothyroidism
•   Multiple Sclerosis                    Parkinson’s Disease             Rheumatoid Arthritis
•   Schizophrenia                         Systemic Lupus Erthematosus     Ulcerative Colotis
Factors driving costs upward in 2004
• Prescribed Minimum Benefits

• Pay for:
   – Consultations
   – Medication
   – Medical Management (Pathology & Radiology)

• Cost-saving measures
   – Care Plan (list of approved consultations & tests)
   – Formulary (list of approved drugs)
   – MMAP (Generics)
• Estimate additional cost of 3% (but full impact unknown)
Member Demands for more
Affordable Medical Aid
• Driven by lower income earners
• Assessed Discovery Health, Ingwe, ThebeMed & Open
  Plan.
• Benefits lower than BPSA
• Contributions higher, increased co-payments.
• Feedback from members:
•      Savings Accounts not Feasible
•      No co-payments
•      Higher day-to-day benefits
•      Higher optical benefits
Meeting Demands

Spectacle Benefits


• R1000 per beneficiary
• 2 year cycle: 2003/2004
• Includes hard-coating
• Limit excludes consultation
   – 80% of Optical Association Tariffs
Meeting Demands

Consultations


• PMB Conditions
• 100% of medical aid rates
• Care Plan will confirm:
   – Number of approved consultations, and
   – Type of consultation (e.g. GP or Specialist)
Meeting Demands
Consultations
• Non-PMB Conditions
• 4 consultation @ 100% of medical aid rates, per
  beneficiary
• Thereafter @ 80%
• Limits:           M            R 3 000
•                  M+1           R 4 000
•                  M+2           R 5 000
•                  M+3+          R 6 000
• Once limit is reached, only consultations for PMB
  conditions will be paid
Meeting Demands

Chronic Medication
• PMB Conditions
• 100% of cost from Direct Medicines
• Subject to:
   – Care Plan
   – Formulary (list of approved drugs)
   – MMAP (generics)
• If Direct medicines is not used, co-payment equals
  difference between:
   – Direct Medicines price and
   – Actual cost
Meeting Demands

Chronic Medication
• Non-PMB Conditions
• 80% of cost (after discount) from Direct Medicines;
  co-payment is 20% of cost
• Subject to
   – Pre-authorisation
   – MMAP (generics)
• If Direct Medicines is not used, co-payments equals:
   – 20% of cost (after discount)
   – plus difference between Direct Medicines price and actual
     cost
Meeting Demands

Chronic Medication


• Limit R 16 500 per beneficiary
• Limit applies to PMB & non-PMB conditions
• When limit is reached, only PMB medication will be paid
Meeting Demands

Direct Medicines


• Mail-order pharmacy in Johannesburg
• Complete application form
• Fax to Direct Medicines with script
• Direct Medicines will deliver your chronic medication to:
   – Home address
   – Office
   – Closest Post Office
Meeting Demands

Acute Medication
• 100% of cost up to R500 per beneficiary
• Thereafter 80% of cost
• Subject to MMAP (generics)
• Limits:          M            R2118
•                  M+1          R3328
•                  M+2          R3751
•                  M+3+         R4145
• Over the counter medication: R65 per ailment,
  included in above limits
Other Benefit Changes
Prosthesis: External & Internal
• 100% of cost from designated service provider
• Limit of R 8 000 per beneficiary per prosthesis; except:
•   Knee Replacement          R 16 500
•   Total Hip Replacement     R 16 500
•   Pacemaker                 R 16 500
•   Cardiac Valves                   R 16 500
•   Cardiac Stents                   R 16 500
•   Partial Hip Replacement   R 13 000
•   Spinal Fusion             R 13 000

• Overall limit of R 16 500 per beneficiary per annum
Other Benefit Changes
Private Hospital Accommodation


• 100% of cost at MediClinic Hospitals
• 10% co-payment at other Hospitals
• Co-payment will not apply if:
   – If you live outside 25km radius of MediClinic Hospital, or
   – if the service is not available at MediClinic Hospital, or
   – emergency admissions
• List of MediClinic Hospitals in Communication Pack
• Choose specialists who practice in MediClinic facilities
• Subject to pre-authorisation
Other Benefit Changes

Emergency Ambulance
ER24
From 1 January 2004
084 124


Loyalty Programme
The Good Life Programme
From 1 January 2004
Other Benefit Changes

HIV/AIDS (Part I)
• HIV ELISA test
• 5 GP consultations
• Anti Retroviral medication
• Anti Retroviral prophylaxis
• Pathology tests
• ‘Flu vaccine
• Dedicated information line
Other Benefit Changes

HIV/AIDS (Part II)
• 100% of Agreed Tariff
• Limits:
• R 30 000 per beneficiary per annum for pathology,
  medication & consultations
• R 30 000 per beneficiary per annum for hospitalisation &
  related services
• Subject to registration on & compliance with programme
• Strictly Confidential!
Other Benefit Changes

Ex-Gratia Awards


Budget =    R 200 000 for financial hardship
            R 200 000 for consultations


Ex-Gratia Committee meets at month end
Completed applications by mid month
Costs for 2004 vs 2003
                        2003 Benefits   2004 Benefits   % Increase
In-Hospital Costs       715             792             11%
GPs & Specialists       103             158             54%
Radiology & Pathology   58              65              11%
Day-to-day Medicines    171             203             19%
Chronic Medicines       178             215             21%
Dentistry               69              77              11%
Optical                 38              44              17%
Other                   47              52              11%
PMB                      0              35              N/A
Emergency Ambulance      3               3              5%
Administration fees     65              68              5%
Managed Care fees       16              17              5%
Other                   26              27              5%
Total required          R 1 487         R 1 755         18%
Cost for 2004 vs 2003

• Benefits increased from 1 January 2004
• Contributions increase from 1 April 2004
• Actual increase will be 10%
• Save costs through:
   – Responsible behaviour of members
   – Introduction of measures to contain costs
   – Discounts offered by MediClinic and Direct Medicines

								
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