Docstoc

December 2010 - Dear Member

Document Sample
December 2010 - Dear Member Powered By Docstoc
					   newsletter                                        december 2010

     Dear Member
     With just a few weeks to go to the end of another year, most of us are wondering just what has
     happened to the last year. It’s hard to believe that the shops are filled with festive season decorations
     and a few of us are lucky enough to have the prospect of some well-earned leave to look forward to. It
     is also time for us to share news on changes to your Scheme benefits and contributions for next year.

     Industry developments in the past year have once again proven to be most challenging and we await
     finalisation on some rather pertinent issues currently on the go in the industry. The uncertainty as to
     how these changes will impact on us means that we need to review the benefits and contributions with
     a fair amount of caution.


     Added to this              is our aim to keep contribution increases as low as possible and we are
     sure you can appreciate that this is no mean feat.
                                                                                               Continued overleaf




                                                                                   Ensuring optimal use of your
Benefits for 2011 explained                                                        Scheme benefits
                                         ER24 – your new Emergency
Your contributions for 2011              Services Provider                         What you need to know about high
                                                                                   blood pressure
Maternity benefits explained             What to do when you’ve been
                                         involved in a car accident                Remember that your MSA is your
Register your newborn within
                                                                                   money – spend it wisely
30 days of birth                         Motor vehicle accident claims –
                                         the correct procedure to follow           Dentistry: know your rights
Preferred Provider Pharmacy
Network                                  Health risks of excess weight             Seven easy diet tricks
newsletter   Continued from previous page
         Reference Price List set                 it is vitally important that you
         aside by High Court                      contact them when you require
         The annual review process starts         an ambulance, whether it is as a
         off as early as August and was           result of an accident or a medical
         made even more challenging this          emergency in your home.
         year by the fact that the High Court
         set aside the Reference Price List,      Other matters
         which was used as the basis for          In addition to news about the
         determining a guideline of fees for      benefits and contributions for next
         practitioners - typically the fees       year, we also bring you some useful
         that medical aids would cover.           information on how to best utilise


                                                                                          BENEFITS
                                                  your medical aid to ensure that
         We are confident that we have            your medical rands stretch further
         provided an adequate increase in         and that you receive the quality of
         both the tariffs and the benefit
         limits for next year so as to
                                                  care that you are entitled to.
                                                                                          FOR 2011
                                                                                          EXPLAINED
         minimise the impact of out-of-           Included in this mailing are detailed
         pocket payments by you, our              benefit and contribution schedules
         members. We remain hopeful that          for next year - make sure you read
         this matter will be finalised early in   these carefully so that you know        Our healthcare actuaries put a
         the new year.                            what your benefits are and so that
                                                                                          lot of work into ensuring that
                                                  you may make optimal use of your
         New pharmacy network                     medical aid.                            the benefit changes we bring
         and emergency services                                                           you each year will ensure that
         provider                                 Thank you for your support              you are still receiving good
         Another legislative matter that will     It would be most remiss of us not       value for money.
         potentially impact on our members        to acknowledge the continued
         is that the new draft dispensing         support that we receive from our        One of their biggest challenges is to
         fees have finally been published         members and to thank you for the        try to increase the Scheme rate (the
         for comment in the Government            way that you have managed your          rate at which we reimburse claims), as
         Gazette. The dispensing fees are         medical aid during the last year.       well as the benefit limits, sufficiently
         the markups that pharmacies may                                                  so that we pay claims at a fair rate
         charge on medication.                    Should you be travelling on the         of remuneration and that the benefit
                                                  roads during the holiday season,        limits are enough to see that you have
         As these proposed dispensing fees        we urge you to take care and to         very reasonable medical aid cover.
         are likely to have a major impact        travel safely. Whether you are at
         on the cost of medication, we            home or away, we hope that your         This year is slightly different, as the
         have set up a pharmacy network           festive season is filled with much      Reference Price List (RPL) for 2010
         with preferential rates - again in       laughter and happiness and we           was set aside by the High Court of
         an effort to limit out-of-pocket         wish you a healthy 2011.                South Africa and, as such, there is no
         expenses. More information on the                                                indication of what providers will be
         network will be provided later on in     We look forward to being of             charging next year. As a result of this,
         this newsletter.                         continued service to you next year.     we have had to redefine our Scheme
                                                                                          rate.
         We have also appointed a new             Kind regards
         emergency services provider and          Your Board of Trustees                  In doing this, we went back to the last
                                                                                          valid RPL and increased this by 42%,
                                                                                          an amount we believe to be equal to
                                                                                          medical inflation.

                                                                                          Should the industry dispute around
                                                                                          the RPL be resolved in time for next
                                                                                          year and a new, valid RPL published for
                                                                                          2011, we will use this as the basis for
                                                                                          determining our Scheme rate.

                                                                                          Benefit limits increased by 7.5%

                                                                                          We have also increased all the
                                                                                          specified benefit limits, including the
                                                                                          overall annual limit, by 7.5% from
                                                                                          1 January 2011. Please refer to the
                                                                                          enclosed benefit schedule for 2011
                                                                                          for further details on the increased
                                                                                          limits.



                                                                      2
                                            Some benefits to be paid from               Routine preventative
                                            overall annual limit in future              procedures available annually

                                            An additional benefit that has been         In an attempt to ensure that our
                                            added for next year is the post-            members maximise the benefits
                                            hospitalisation appliances benefit.         available to them, we have included
                                            In the past, when members have had          a list of tariff codes that are covered
                                            an operation and have required some         under the preventative procedures
                                            appliances such as special anti-clotting    benefit. This benefit allows members
                                            stockings – or in the case of joint         access to a couple of routine
                                            replacements, crutches or wheelchairs       procedures on an annual basis to
                                            – these have been paid from the             ensure that you remain as healthy as
                                            Medical Spending Account (MSA).             possible.

                                            For 2011, these appliances will be          These are listed in detail in Annexure
                                            paid from the overall annual limit. It      C of the benefit schedule that has
                                            is, however, important to remember          been included with this newsletter.
New limit for out-of-hospital               that these appliances have to be            Please ensure that when you visit a
pathology and radiology                     pre-authorised by MSO. Their contact        provider for one of these procedures
                                            details are included in this newsletter.    that he or she knows to charge these
We are introducing a limit for out-                                                     tariff codes. By doing this, it will
of-hospital pathology and radiology         We have also changed the way that           ensure that the procedures are paid
for next year. We analysed the claims       occupational and speech therapy             from the correct benefits and not
received for pathology and radiology        for in-hospital patients are paid.          from your MSA.
for 2009 and 2010 and are confident         Previously, these services were paid
that the limits will be sufficient to       from the member’s MSA, even though
cover any radiology or pathology
treatment you or your family may
                                            the patients were still in hospital when
                                            receiving the treatment. These will
                                                                                        Call us if you
require.

As such, a per family limit of R3 500
                                            now be paid from the overall annual
                                            limit as well.                              have any queries
has been introduced for pathology and       Again, provided that the therapy has
a separate limit of R3 500 per family       been approved by MSO. Please bear in
for radiology.                              mind that you will also need to obtain
                                            pre-authorisation from MSO if you
                                                                                           We have covered some of
It is important to remember that while      need to receive physiotherapy as part
the following benefits accrue to this       of a hospital event.                           the other benefit changes
limit, they are not subject to the limit:                                                  in more detail further on
•	 prescribed minimum benefit (PMB)         Lasik eye surgery no longer                    in the newsletter. Please
    conditions, as provided for in your     routine                                        make sure that you read
    care plan;                                                                             these carefully. Should you
•	 scans and tests afforded to you          After careful evaluation, it has been
    under the maternity programme;          decided that Lasik eye surgery will no
                                                                                           have any queries on the
    and                                     longer be covered by the Scheme as             benefit changes for next
•	 preventative care benefits.              a routine procedure. However, should           year, please contact our
                                            you have a strong motivation for               Client Service Team on
In other words, should you have used        having the procedure done, supported           0800 004 389. They will
the full R3 500 for out-of-hospital         by clinical records, please submit your
                                                                                           gladly assist you with your
pathology or radiology or to treat          motivation and clinical records to the
medical conditions and you or your          Client Service Team, who will refer it to      questions.
dependant now need to go for blood          the medical advisor for re-evaluation.
tests that are covered either by your
care plan or the maternity programme
or under preventative benefits, these
                                              Additional conditions added to
will still be paid in accordance with the
                                              chronic medication programme
Scheme’s rules. However, if you have
not used the full R3 500 yet, these
                                              Stroke, phlebitis and thrombophlebitis
services will be paid from (or accrue
                                              have been added to the list of chronic
to) the R3 500 limit.
                                              conditions for which the Scheme will
                                              provide chronic medication. Should
Please note that the limit of R3 500
                                              you have one of these conditions,
per family for out-of-hospital
                                              please ask your doctor or pharmacist
pathology or radiology does not apply
                                              to contact the Scheme’s chronic
to in-hospital pathology or radiology
                                              medication provider on 0800 123 345
like MRI and CT scans. These need
                                              to discuss having the medication
to be pre-authorised by MSO, our
                                              authorised.
managed care provider.

                                                               3
newsletter
                                                                                      MATERNITY
             YOUR CONTRIBUTIONS                                                       BENEFITS
             FOR 2011                                                                 EXPLAINED
             We realise that the last year has been really tough on
             everyone and even though the economy has started to                      During 2010, we introduced the
             recover, it is going to take a while still. For this reason,             new improved maternity programme
             we have tried very hard to minimise the impact that                      to you. For the first time, we
             unavoidable contribution increases will have on our                      will now pay for some of your
                                                                                      consultations, scans and blood
             members.
                                                                                      tests from the overall annual limit
                                                                                      and not from your Medical Spending
             We do, however, need to increase    have retired prior to January        Account (MSA).
             the contributions to ensure that    2011 and you wish to have
             the Scheme remains financially      your contribution band re-           You will have to register on the
             viable and that we keep up with     evaluated, we will calculate your    maternity programme before
             medical inflation. Without an       contribution rate by taking 60%      qualifying for these benefits. To
             increase we would not have          of your last salary and increasing   register, please contact Private
             been able to introduce some         it by the consumer price index       Healthcare Administrators (PHA)
             of the benefits detailed in this    (CPI) for each year that you have    on 0860 767 633 (option 3) as
             newsletter.                         been retired.                        soon as you discover that you or
                                                                                      your dependant is pregnant. Once
             Income bands adjusted               If you feel that your contribution   you have been registered on the
             In an attempt to minimise           should be reviewed for this          programme, you will be entitled to
             the impact on your pocket,          reason, please submit your written   have the following benefits paid
             we have for the first time in       request to picknpay@mhg.co.za or     from your overall annual limit:
             the Scheme’s history adjusted       fax it to 021 450 6842.
             the income bands by 5%. This                                               •	 one	antenatal,	general	
             means that those members            Contributions increased                   practitioner consultation;
             who are currently at the top of     by 7.8%                                •	 four	antenatal	consultations	
             the income bands will not be        On average, contributions have            at an obstetrician or
             pushed into a higher bracket        been increased by 7.87% for               gynaecologist;
             (with higher contributions) when    2011. A detailed contribution          •	 two	two-dimensional	
             the salary increases come into      schedule has been included with           ultrasounds or
             effect next year.                   this newsletter. Please refer to          scans; and
                                                 this for more details on what          •	 routine	blood	tests	
             We have also introduced a new       your contributions will be.               for abnormalities.
             income band for those members
             earning more than R15 751 per                                            Please remember that these are not
             month.
                                                 Remember to take                     the only benefits you are entitled
                                                                                      to during your pregnancy. It simply
             More affordable
             contributions for                   any subsidies you                    means that you can now have these
                                                                                      benefits paid from your overall
             pensioners
             In addition, we have reviewed the   may qualify for                      annual limit and not from your MSA,
                                                                                      as was the case before 2010. Any

                                                 into account.
             basis for calculating pensioners’                                        consultations in addition to the
             income, making it more                                                   above benefits will still be paid for
             affordable for pensioners to                                             from your available MSA.
             remain on the Scheme when they
             retire. In the past, 75% of your                                         It is important to remember that a
             last working salary was used to                                          sub-limit of R3 500 per family has
             determine your income band for                                           been introduced for radiology and
             the calculation of contributions                                         for pathology for 2011. The scans
             if you wished to remain on the                                           and blood tests that form part of the
             Scheme after you retired.                                                maternity programme benefits will
                                                                                      accrue to this sub-limit, but are not
             For those members retiring                                               subject to it. This means that should
             after 1 January 2011, we will                                            these sub-limits be exhausted, you
             now only use 60% of your last                                            will still be able to have your two
             working salary. Should you                                               two-dimensional scans and the
                                                                                      routine blood tests for abnormalities
                                                                                      done. These will still be paid from
                                                                                      the overall annual limit.

                                                                  4
                                                            PREFERRED PROVIDER
                                                            PHARMACY NETWORK




                                        Background
                                        The Single Exit Price (SEP) regulations, which came into effect in 2005
                                        and which govern the pricing of prescribed medicines (schedules 1 to 7
                                        drugs), have had a massive, positive impact on the medical aid industry.
                                        The regulations dictate that prices can only increase once a year and only
                                        up to a maximum percentage, as published by the Minister of Health in the
                                        Government Gazette.

                                        The fee that pharmacists can add to the SEP for dispensing the medication
                                        was also legislated but has not yet been enforced by Government due
                                        to various legal issues. As a result not all pharmacists adhere to this
                                        dispensing fee and charge an additional “administration” or “service fee”
                                        for which members are liable.



REGISTER YOUR                        Pick n Pay pharmacy network               pharmacies in your area at
                                     In the absence of legislation on the      www.pnpms.co.za or
NEWBORN WITHIN                       fee that a pharmacist may charge to       www.medikredit.co.za.
30 DAYS OF BIRTH                     dispense prescription medication,
                                     the Scheme has entered into an            What do you do if your current
It is very important that you        agreement with certain pharmacies         pharmacy is not on the Pick n
register your newborn baby on        countrywide to charge members             Pay pharmacy network?
the Scheme within 30 days of         only the Scheme rate for chronic and      •	 Please	request	your	pharmacist	
birth.                               acute prescription medicine. This will       to consider joining the Pick n Pay
                                     eliminate further cost to the patient        pharmacy network by phoning
Should you not do this within 30     for dispensing fees or pharmacy              the MediKredit call centre on
days of birth, waiting periods       administration costs.                        0860 93 22 73 for an application
may be imposed, during which                                                      form.
time no claims will be paid in       A list of the Scheme’s recommended        •	 You	may	still	obtain	your	
respect of your baby. We will also   pharmacies will be posted on our             prescription from your current
not cover any claims for the baby    website by the middle of December            pharmacy and pay the additional
relating to the birth.               2010. This is a dynamic list and             costs where relevant.
                                     will grow in the first few months
For example, we will not be          as pharmacies sign contractual            What happens if you do not
able to pay the paediatrician or     agreements with the Scheme. Please        change to a pharmacy on the
pathologists’ claims that may        make use of the network pharmacies.       Pick n Pay pharmacy network?
have arisen while mom and baby       It will assist you in managing your       Scheme members are not forced to use
were in hospital at the time of      medication benefit, as well as avoid      these pharmacies, but should the out-
birth.                               additional co-payments.                   of-network pharmacy charge a higher
                                                                               dispensing fee than allowed on the
Please contact your HR               This is a Pick n Pay Medical Scheme       pharmacy network, you will be liable for
department as soon as the baby       initiative to manage members’ out-of-     the co-payment, i.e. the difference be-
is born to arrange this.             pocket expenses at pharmacies. Please     tween the Scheme’s agreed rate and the
                                     refer to the list for recommended         dispensing fee charged by the pharmacy.

                                                        5
newsletter
             ER24 - YOUR NEW EMERGENCY
             SERVICES PROVIDER
             We are pleased to announce that we have appointed ER24 as the new emergency
             services (ambulance) provider for Pick n Pay Medical Scheme from 1 January 2011.

             ER24 is an international assistance company and             ER24 offers a 24-hour integrated service to all
             emergency medical care provider in South Africa,            their clients. Their clinical staff are all highly
             specialising in the pre-hospital environment.               specialised in emergency care and include
                                                                         friendly and helpful professional nurses and
             ER24 will, with effect from 1 January 2011,                 paramedics who are supported by the ER24
             provide Scheme members with emergency medical               Chief Medical Officer. Daily transfer of Scheme
             services throughout South Africa as well as in              data allows providers to confirm members’ status
             Lesotho and Swaziland.                                      afterhours.

             ER24 has in excess of 200 rapid response vehicles
             and ambulances stationed at bases around the                In addition, members have access
             country. This national network includes basic,              to a 24-hour crisis counselling
             intermediate and advanced life support emergency
             services. Together with additional quality-                 line where trained healthcare
             controlled contracted service providers, their
             national footprint ensures prompt response from
                                                                         professionals will assist with :
             the most appropriate team of paramedics at all
                                                                         •   HIV/AIDS information;
             times. If a member needs to be airlifted to hospital,
                                                                         •   trauma counselling;
             ER24 also has helicopter and fixed wing air
                                                                         •   bereavement counselling;
             ambulances in specific locations around the country
                                                                         •   rape counselling and referral to rape centres;
             to ensure the fastest possible response times.
                                                                         •   family, domestic and child abuse counselling;
                                                                         •   substance abuse counselling;
             In order to ensure efficient and effective call-
                                                                         •   poison advice; and
             taking and call-handling, ER24 uses one national
                                                                         •   suicide hotline.
             number 084 124 operated through a high-tech
             emergency contact centre, 24 hours a day. This
             centre is supported by highly trained and extremely
             dedicated operators who make immediate, informed
             decisions about the nature and extent of the call.
             Sophisticated despatching software, mapping
             technology and medical databases allow the staff
             to provide an immediate service to emergency and
             non-emergency callers.




                                                                             WHAT TO DO IN THE EVENT
                                                                             OF A MEDICAL EMERGENCY:
                                                                             1. Always call 084 124.
                                                                             2. If someone is calling on your behalf, tell
                                                                                them to call 084 124.
                                                                             3. Tell the ER24 operator that you are
                                                                                a Pick n Pay Medical Scheme member
                                                                                - they will prompt you or the caller
                                                                                through all the information they require
                                                                                to get help to you.




                                                                     6
WHAT TO DO WHEN
YOU’VE BEEN INVOLVED
IN A CAR ACCIDENT
Would you know what to do if
you are involved in a serious car
accident where you require onsite
medical assistance, or what needs
to be done to ensure that your
medical bills are settled on time by
the Scheme? Furthermore, do you
know how to lodge a claim with the
Road Accident Fund to recover any
expenses paid by the Scheme? In this
article, we provide you with a step-
by-step guide on dealing with such a
situation.

Firstly, should you be involved in
an accident and either you or one
                                        MOTOR VEHICLE ACCIDENT
of your dependants requires onsite
medical care, it is important that
                                        CLAIMS - THE CORRECT
you contact the Scheme’s dedicated      PROCEDURE TO FOLLOW
emergency service provider, ER24,
                                        In terms of the rules of the Scheme, accounts relating to motor
on 084 124. ER24 will see to it
that an appropriate road and/
                                        vehicle accidents and third-party claims will only be paid when
or air response, whichever is           the Scheme receives a signed undertaking from the member. The
the most medically appropriate          undertaking must state that any Road Accident Fund (RAF) payments
and logistically possible, will be      received by the member or his/her attorney or agents, relating to any
dispatched to the scene of the          medical costs paid by the Scheme for a motor vehicle accident, will
accident. The ER24 personnel will       immediately be paid back to the Scheme.
provide the necessary life saving
support and, if necessary, ensure       1. When you have been injured in        6. If for some reason the RAF
that the patients are stabilised           a motor vehicle accident, you           rejects the claim or divides
before they are transferred to the         should contact the Client Service       payment between a number
closest, most appropriate medical          Department on 0800 004 389 or           of parties, based upon the
facility.                                  the Motor Vehicle Accident (MVA)        possibility of joint negligence,
                                           Department on 021 480 4402              and the RAF payment is limited,
To help you remember the correct           as soon as possible.                    the Scheme will not hold the
contact details for ER24, we have       2. An MVA official will assist you in      member responsible for paying
included stickers in this newsletter       determining whether you need            back any shortfall. Upon receiving
that should be affixed to your car’s       to institute a claim. In terms          proof of settlement from the RAF,
rear window. (Please refer to the          of legislation, any person who          the matter may be finalised.
leaflet from ER24 that has been            is injured in a motor vehicle        7. The attorney, agent or the
included in this mailing and that          accident may claim a variety of         member (depending on who
explains how to affix the stickers to      damages from the RAF, provided          signed the undertaking) should
your car windows.) This will ensure        that the accident was not caused        immediately reimburse the
that any other person who happens          due to their negligence.                Scheme.
upon the scene of the accident will     3. If you can institute a claim, you    8. The case is then closed.
also be able to contact the correct        need to provide the Scheme with
emergency medical response.                a letter of undertaking.

As ER24 provides medical assistance
                                        4. On receipt of the undertaking,
                                           the Scheme will pay all accounts
                                                                                      Remember:
in home emergency situations too,          in accordance with the rules             You will sign an undertaking
we have also included two smaller          of the Scheme and available                promising to refund any
stickers that can be affixed to your       benefits.                                payments from the RAF back
telephone at home, thereby ensuring     5. Payments by the Scheme are                to the Scheme. Should you
that you have the numbers readily on       seen as a loan to the member,           receive payment from the RAF
hand in any emergency.                     which must be repaid once                 and you fail to refund the
                                           recovered from the RAF. Claims          money to the Scheme, you are
Should you require more stickers,          to be settled by the RAF can take       guilty of committing fraud and
please contact our Client Service          anytime from 18 months to three         the necessary legal action will
Team on 0800 004 389 and request           years to recover. As you can well        be instituted against you to
that more be sent to you.                  imagine, no doctor is prepared to       recover the money due to the
                                           wait that long for payment.                         Scheme.


                                                      7
                                                  What is BMI?
newsletter
                                                  BMI stands for Body Mass Index and it is an indicator of how overweight you
                                                  are for your height. It is easier to calculate your BMI if you know your height
                                                  in metres and your weight in kilograms. The calculation is – multiply your
                                                  height by itself (i.e. squared) and then divide your weight by this figure.

                                                    For example, if you weigh 79 kg and your height is 1.64 m, your BMI
                                                    would be:
                                                    1.64 x 1.64 = 2.69 – now divide 79 by 2.69 = 29.37;
                                                    therefore your BMI is 29.37.

         HEALTH RISKS                             If sums are not for you, this chart is a rough guide. If you find your weight on
         OF EXCESS                                the left and trace the line according to the heights on the bottom, it will give
                                                  you an idea of your BMI.
         WEIGHT                                    kg                                                                                           BMI
         With the holidays and the season of       140
         eating and being merry coming up,         135                                                                                          32
         please remember that although a           130
                                                                                                                     SE
                                                                                                                 E
         little of what you like may not harm      125                                                      OB
         you, being overweight is bad for your     120
         health. New research is showing           115
         us more clearly how much being            110                                                                    HT                    27
                                                                                                                     IG
         overweight is costing the medical         105                                                        WE
         scheme population.                                                                                 ER
                                                   100
                                                                                                       OV
                                                   95
         The weighty 30+                           90
                                                                                                                        IG     HT               22
                                                   85
                                                                                                                Y	   WE
         More than 30 illnesses are either         80                                                     LTH
         caused by or made worse by carrying       75                                              H   EA
         excess weight. These illnesses fall       70
         into five broad categories:
                                                   65                                                                           T
                                                                                                                          IGH
                                                   60                                                       WE
         •	 Metabolic, e.g. diabetes, high                                                               DER
            cholesterol, high blood pressure,
                                                   55                                              UN
                                                   50
            gallstones and gout
                                                   45
         •	 Degenerative, e.g. arthritis, joint
                                                   40
            disorders, heart disease, stroke
                                                   35
            and heart attack
                                                   30
         •	 Anatomical, e.g. obstructive
            sleep apnea, reflux (GORD -            cm    140   145   150   155   160   165   170   175      180           185       190   195

            “heartburn”), reflux-related
            asthma, hernias, swelling, blood      The risk of death from heart disease is more than three times greater for
            clots in legs and lungs and           overweight people and up to six times greater for people with obesity.
            infections of the skin
         •	 Cancer, e.g. womb lining, breast,     If your BMI is over 30 and you have a chronic condition, as a member of
            ovaries, prostate, colon (bowel)      the Pick n Pay Medical Scheme you have access to the Health Management
            and oesophagus (gullet)               Programme where you will be assisted with managing your weight.
         •	 Psychological, e.g. depression,
            anxiety, bulimia and binge-eating.    If your BMI is over 35 and you require an operation to a weight-bearing
                                                  joint, for example your knees or hips, authorisation for this procedure may
         In addition to the burden of chronic     be delayed until such time as you have managed to reduce your BMI to below
         illnesses, the costs of surgery and      35. Pick n Pay’s Health Management
         hospitalisation are also increased by    Programme will assist you with
         obesity due to higher complication       reducing your BMI and getting you
         rates, longer length of stay, higher     fighting fit for your operation.
         need for intensive care, longer
         theatre times, delayed healing and       We encourage you to contact
         anaesthetic risks. Compared to           one of the nurses on the Health
         people with a normal weight those        Management Programme by
         who are overweight have a 60%            calling 0860 767 633 and
         greater risk of dying within 10          choosing option 4 from the
         years. This risk is more than twice as   voice prompts. Alternatively you
         high for people with obesity (a BMI      can e-mail us at
         of 30 or more).                          pnphealth@pha.co.za.

                                                                8
ENSURING OPTIMAL USE OF YOUR
SCHEME BENEFITS
It is becoming increasingly important for members to understand and use their Scheme benefits
correctly and conservatively. In this way, you will ensure that your benefits last a lot longer and are
available when you become ill and need them the most. Remember that you have a responsibility
towards yourself and your family!

Remember to contact MSO for                Should you voluntarily choose to use a     Bear this in mind when you are
pre-authorisation                          hospital belonging to a group outside      referred to a specialist by your
It is vitally important that you           of the PPN, you may be faced with a        general practitioner. Ask him/her to
contact MSO for authorisation on           co-payment of R1 000. Remember             refer you to a specialist at a PPN
0860 767 633 (option 1) at least           though that no co-payment will be          hospital if there is one in close
48 hours prior to being admitted to        levied should you be admitted to a         proximity. For a detailed list of which
hospital. This authorisation number is     non-PPN hospital during an emergency       hospitals form part of the PPN, please
not a blanket guarantee of payment         or if there is no PPN hospital within a    contact the Client Service Team on
for all procedures and tests performed     25 km radius of your home.                 0800 004 389.
in hospital. Very few doctors still
charge what the Scheme will pay and
unless you negotiate with your doctor
to charge you reduced rates, you may
face large co-payments once you have
                                              SOME OTHER USEFUL TIPS WHEN USING
been discharged and the bills start           SCHEME BENEFITS
coming in.                                    •	 Ensure	that	your	service	provider	includes	the	correct	ICD-10	diagnosis	
                                                 codes on your invoice or claim.
Find out what you are                         •	 Ensure	that	all	claims	are	submitted	on	time,	as	claims	older	than	four	
covered for                                      months will be regarded as stale and cannot be paid by the Scheme.
Furthermore, make sure that you               •	 Understand	the	rules	of	the	Scheme,	allotted	benefits,	benefit	limits	and	
understand what benefits you are                 if there are any criteria to qualify for such benefits.
entitled to and what will be covered          •	 Where	available,	use	generic	instead	of	brand-name	medication	to	
by the Scheme. Ask your doctor for a             conserve your medication benefits. Consult your doctor or pharmacist if
list of tariff codes for the procedures          you are unsure.
to be performed and what the doctor           •	 Only	use	pharmacies	who	do	not	levy	a	co-payment	to	members.	
charges for those procedures. Once               Remember that you will have to make these co-payments out of your
you have this information, please feel           own pocket.
free to contact the Client Service Team       •	 Ask	your	doctor	to	charge	you	medical	scheme	rates	instead	of	private	
on 0800 004 389. They will be able               rates. Don’t be afraid to negotiate. You might otherwise end up with
to advise you on what will be paid by            huge co-payments.
the Scheme. This applies to out-of-           •	 Check	your	claims	statements	for	correctness.	Ensure	that	your	
hospital procedures as well.                     membership details are correct and true and that the Scheme is only
                                                 billed for services received by you. Report any fraudulent claims and
Remember that if authorisation for               query any incorrect deductions with the Scheme’s Client Service Team.
hospitalisation is denied, it does            •	 Make	sure	that	your	Scheme	membership	number	is	included	on	all	claims	
not mean that you cannot have                    submitted. Remember, this number is different to your employee number.
the procedure done. It does mean,                The Scheme does not have access to your employee number. Including
however, that you will be liable for all         this number on your claims instead of your membership number will
costs relating to the hospitalisation.           result in delays in processing of claims.
The same goes for any other tests or          •	 Read	Scheme	communication	carefully	and	empower	yourself!	Get	
procedures for which the Scheme does             involved in the activities of the Scheme, e.g. attend the Annual General
not pay. You need to discuss your                Meeting.
various options with your doctor and          •	 Ensure	that	all	scheduled	hospital	procedures	are	pre-authorised.	These	
together decide on whether you still             costs might otherwise be paid from your savings.
need to have the procedure or tests           •	 Keep	all	the	relevant	contact	numbers	of	the	Scheme	handy	for	future	
done.                                            reference.
                                              •	 Consult	your	pharmacist	for	minor	ailments	such	as	colds,	flu	or	cuts,	
Make use of the Scheme’s                         or clinical screening tests such as blood pressure monitoring and blood
preferred hospital network                       sugar testing. This can save you the cost of a doctor’s consultation.
The Scheme has negotiated
preferential rates with a group of
hospitals, referred to in the Scheme          By empowering yourself with the necessary knowledge regarding the
rules as the Preferred Provider               Scheme and its rules and benefits, you will receive maximum benefit
Network (PPN) of hospitals. As such,          and peace of mind for you and your loved ones. Discreet and sensible
should a member be admitted to one            use of your benefits will ensure that they last longer, are available
of these hospitals, no co-payment will        when you need them and that annual contribution increases are within
be applied.                                   inflationary parameters.


                                                             9
newsletter
             WHAT YOU NEED TO KNOW ABOUT
             HIGH BLOOD PRESSURE
             What is high blood pressure?                                   Is high blood pressure life threatening?
             High blood pressure or hypertension occurs when                High blood pressure is dangerous because it causes
             the force of blood against the artery walls is too             the heart to work very hard. This added strain
             strong. It occurs when arterioles (smaller blood               on the heart leads to heart attacks and stroke.
             vessels) become constricted, making it difficult               When the heart is forced to work extra hard for
             for blood to pass through them. This leads to a                an extended period of time, it tends to enlarge. A
             rise in blood pressure, which causes an increase               somewhat enlarged heart can function well, but a
             in the workload of the heart. If your resting blood            significantly enlarged heart cannot.
             pressure stays at 140 over 90 or more, you may
             have high blood pressure.                                      People	with	uncontrolled	high	blood	pressure	
                                                                            are:
             High blood pressure is called a “silent killer”                •	 three	times	more	likely	to	develop	coronary	heart	
             because it is symptom free unless it is very high.                disease;
             It can cause major organ damage if left untreated.             •	 six	times	more	likely	to	develop	congestive	heart	
             High blood pressure is a dangerous condition.                     failure; and
             It damages the arteries and may lead to a heart                •	 seven	times	more	likely	to	have	a	stroke.
             attack, kidney failure or stroke.
                                                                            Can high blood pressure be treated?
             What is the “ideal” blood pressure?                            High blood pressure can be successfully treated.
             There is no “ideal” blood pressure reading.                    Moderate forms of high blood pressure can be
             Generally, a blood pressure reading that is less than          treated through lifestyle changes such as adopting
             140 over 90 indicates that you are fine. However, if           a healthier diet and performing more physical
             either or both numbers are equal to or greater than            activity. More severe cases of high blood pressure
             140 over 90 for an extended period of time, you                may require individualised medical treatment.
             have high blood pressure.
                                                                            Tips for lowering your blood pressure
             Risk factors                                                   Most people can adopt simple lifestyle changes
             You	may	be	at	greater	risk	for	high	blood	                     to prevent and manage high blood pressure. We
             pressure if you:                                               recommend the following, amongst others:
             •	 are	a	male;                                                 •	 Have	your	blood	pressure	checked	regularly.
             •	 are	over	35	years	of	age;                                   •	 Eat	healthy	foods,	including	fresh	fruits	and	
             •	 smoke;                                                         vegetables.
             •	 are	obese;                                                  •	 Maintain	your	ideal	body	weight.
             •	 have	a	strong	family	history	of	high	blood	pressure;        •	 Exercise	regularly.
             •	 have	a	pre-existing	condition	such	as	diabetes	or	          •	 Stop	smoking.
                high cholesterol;                                           •	 Manage	your	stress	levels.
             •	 frequently	enjoy	alcoholic	drinks;	and                      •	 Limit	your	alcohol	intake.
             •	 lead	a	sedentary	lifestyle.

                                               Health Management
                                                       Programme                           Pick n Pay Medical Scheme has a
                                                                                           Health Management Programme
                                                                                           that can assist you in lowering
                                                                                           your high blood pressure. To
                                                                                           register on this programme,
                                                                                           please contact us by calling
                                                                                           0860 767 633 and choosing
                                                                                           option 4 from the voice prompts.
                                                                                           Alternatively you can e-mail us
                                                                                           at pnphealth@pha.co.za.




                                                                       10
REMEMBER THAT
YOUR MSA IS
YOUR MONEY -
SPEND IT WISELY
Did you know that 25% of
your monthly contribution
is allocated to your Medical
Spending Account (MSA)?
This is in effect your
money. Although it is used
to pay for certain day-to-
day benefits, it remains
your money. What you don’t
use in a particular year is
rolled over to the next year.
We don’t take away what
                                                                            DENTISTRY:
was left over in your MSA                                             KNOW YOUR RIGHTS
at the end of the year.                Your teeth are a valuable asset and it is worthwhile investing in their care. It
                                       is, however, important that you are aware of your rights and obligations as
You also have an opportunity to earn   a patient. Irrespective of whether you are a private patient or a member of
interest on balances left over from    the Scheme, ultimately you are personally responsible for payment of dental
the previous year, thereby growing     services.
the balance in your MSA.
                                       So how does this affect you and what can you do to
Should you at any stage leave the
                                       ensure that you are getting a “fair deal”?
Scheme and you have money left over
in your MSA, we will pay the funds     •	 Find	a	dentist	you	trust	and	with	whom	you	feel	comfortable	and	at	ease.
out to you after a period of four      •	 Don’t	be	shy	to	ask	what	the	dentist	intends	doing	and	how	much	it’s	going	
months from the date of resignation.      to cost, before treatment commences.
                                       •	 If	you	are	unsure	about	the	proposed	treatment,	for	financial	or	other	
You may use your rolled-over MSA          reasons, ask your dentist if there are alternative options.
balances to pay out-of-pocket          •	 You	are	entitled	to	a	written	cost	estimate.	You	may	submit	this	to	the	
medical expenses. For example,            Client Service Department to ascertain what benefits are allocated for the
should you have a particularly large      particular service.
private portion of a claim that you    •	 If	you	are	still	not	sure,	it	is	your	right	to	go	to	another	dentist	for	a	
need to settle, you can request that      second opinion regarding both the appropriate treatment and the cost.
this amount be used to pay for it.        (You will naturally be expected to pay for the second opinion.) You may also
                                          request copies of your clinical records and X-rays, but could be required to
For these reasons, it is important        pay a copying fee for these.
that you try to use your MSA very
conservatively to save for a rainy     With this information, you will hopefully be able to make an informed decision
day when you might have major          about what you need and can afford in respect of your personal dental
medical expenses or for the day        treatment.
when you leave the Scheme and need
to move to another medical aid.        Source of information: The Dental Ombudsman

                                                       11
SEVEN EASY
DIET TRICKS
Achieve your desired weight, break
unhealthy habits and look after your
heart with these ridiculously simple
diet tricks!                                                                             WE WOULD LIKE TO
                                                                                         HEAR FROM YOU
1    Limit unhealthy fats and              are low in calories and rich in
     cholesterol                           dietary fibre. Vegetables and fruits          If you have ideas for future
                                           also contain substances found                 articles, suggestions for
Of the possible changes, limiting how      in plants that may help prevent               improvements to your
much saturated and trans fats you eat      cardiovascular disease.                       benefits, or even if you
is the most important step.                                                              have concerns you believe
                                                                                         other members should
Check the food labels of some              4     Select whole grains                     know about, we would like
cookies, crackers and chips. Many of                                                     to hear from you.
these snacks - even those labelled         Whole grains are good sources of fibre
“reduced fat” - may be made with oils      and other nutrients that play a role in       Send your e-mails to
containing trans fats. One clue that       regulating blood pressure and heart           picknpay@mhg.co.za and
a food has some trans fat in it is the     health. Many products on the market           look out for our response
phrase “partially hydrogenated” in the     are whole grain, such as popcorn and          in the next issue of our
ingredients list.                          flaxseed. And some cereals are also           newsletter.
                                           wholegrain and are mentioned on the
When you do use fats, choose               label of the product.
monounsaturated fats, such as olive
oil or canola oil. Polyunsaturated fats,
found in nuts and seeds, are also good     5     Reduce the salt in your                     important
choices for a heart-healthy diet. But            food                                      contact details
moderation is essential. All types of
fat are high in calories.                  Eating a lot of salt can contribute to
                                           high blood pressure, a risk factor for
                                           cardiovascular disease. Eating fresh        CLIENT SERVICE DEPARTMENT
2    Choose low-fat protein                foods and making your own soups and         Tel: 021 480 4801 or
     sources                               stews can reduce the amount of salt         0800 004 389
                                           you eat.                                    Fax: 021 480 6842
Be careful to choose low-fat options,                                                  Postal address: PO Box 15774,
such as skimmed or low-fat milk in                                                     Vlaeberg 8018
place of full cream milk and meat          6     Allow yourself an                     E-mail: picknpay@mhg.co.za
should have all visible fat trimmed off.         occasional treat                      Internet: www.pnpms.co.za

Fish is another good alternative to        Allow yourself an indulgence every          HOSPITAL AND ONCOLOGY
high-fat meats. Certain types of fish      now and then. A candy bar or handful        PRE-AUTHORISATION
are heart-healthy because they are rich    of potato chips won’t derail your           Tel: 0860 767 633
in omega-3 fatty acids, which can lower    heart-healthy diet. If over-indulgence
fat in blood. The highest amounts of       is the exception, rather than the rule,     MANAGED CARE PROGRAMMES
omega-3 fatty acids are in cold-water      you’ll balance things out over the long     Tel: 0860 767 633
fish, such as salmon, mackerel and         term. What’s important is that you eat
herring. Other sources are flaxseed,       healthy foods most of the time.             CHRONIC MEDICATION
walnuts, soybeans and canola oil.                                                      Tel: 0800 132 345 (doctors only)

Legumes - beans, peas and lentils -        7     Sugar can be enjoyed in               CENTRE FOR DIABETES AND
are also good sources of protein and             moderation                            ENDOCRINOLOGY
contain less fat and no cholesterol,                                                   (Diabetes Management
making them good substitutes for meat.     Many healthy foods, such as all bran        Programme)
                                           cereal, are not really that enjoyable       Tel: 011 712 6000 (office hours)
                                           without a little sugar. Sugar does help     Internet: www.cdecentr.co.za
3    Eat more vegetables and               us to follow a healthy diet and, when
     fruits                                eaten as part of a healthy diet, will not   ER24
                                           cause heart disease.                        Emergency Transportation
Vegetables and fruits are good                                                         Services
sources of vitamins and minerals; they     Source of information: Health24.com         Tel: 084 124

                                                                 12

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:6
posted:2/13/2011
language:English
pages:12