CompCare_2015_Product.pdf

Product summary2015

Product overview

CompCare Wellness has implemented overall benefit and limit enhancements of 6% across all options for 2015 whilst limiting contribution increases to 8.9% on all options.

CompCare is financially strong with a solvency level of 38%, considerably higher than the 25% minimum required by the Council for Medical Schemes.

Those who are new to the Scheme will find that CompCare is sensitive to both healthcare and budgetary needs with no less than eight benefit options to choose from as well as efficiency discounted options for those that may prefer using designated service providers in return for a more affordable contribution rate.

CompCare has introduced a few exciting new benefits: Utilisation of Universal Network Providers (GP, dental, optometrists) will earn you 10% of the

payment amount into your AFB++ account A referral by your Universal Network provider GP to a specialist will earn you 10% to your

AFB++ account CompCare has always been concerned about individuals health so look at the new Newborn

to Adult and Emotional Wellness benefits.

We trust that this summary will provide you with relevant information on the benefit options that we offer, that will not only help you to stay well, but also cover your health costs when in need.

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CompCare Medical Scheme offers a wide range of options to take care of most peoples healthcare needs. The options offer a wide range of benefits at affordable prices.

The Mumed option is an affordable plan with traditional benefits for young members and families who want the freedom to see a healthcare provider of choice when necessary.

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The Pinnacle option offers comprehensive cover for the discerning achiever, with exceptional hospital and superior day-to-day benefits comprising a combination of savings account, traditional risk cover and very competitive above threshold benefits.

The Excess Direct option, a traditional type of option which requires members to contribute 20% of the cost of any out of hospital healthcare services, whilst a sliding scale co-payment is applied for hospital accounts with a limit of R10 000 per admission.

Excess Direct

Dyn

amix The Dynamix option is an attractive

new generation plan that offers comprehensive private hospital cover, a savings account and traditional risk benefits with above threshold benefits for day-to-day healthcare expenses.

The Axis option is a premium comprehensive private hospital benefit plan with post-operative rehabilitation benefits for complete peace of mind.

Axis

Sym

met

ry The Symmetry Option provides unlimited cover in a private hospital of your choice and comprehensive day-to-day benefits and traditional risk cover, for complete peace of mind.

The NetworX option is an affordable healthcare plan with exceptional value for students and low-income employees in the corporate sector, and offers essential cover within the Universal Healthcare Provider Network.

Netw

orX

BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED EXCESS DIRECT AXIS NETWORX

Hospitalisation

Hospitalisation (private hospitals and

nursing homes)

100% of AT - Treatment subject to

pre-authorisation, case management and

Scheme protocols

100% of AT - Treatment subject to pre-

authorisation, case management and Scheme protocols





Access to Private Hospitals is covered up to the Overall Annual Limit at 100% of cost

and there after unlimited through Public Hospital facilities. Co-payment applies to the Hospital

Account at Private Hospital Facilities. 50% of the first R4 650 per

incident for the members account thereafter 10% of the remainder, up to a maximum co-payment of

R10 000




authorisation, case management and

Scheme protocols in a Preferred

Hospital Network

Efficiency Discount

Members will receive a discount on contributions if Netcare Hospitals are

selected as their preferred provider for in-hospitals treatment and if chronic medicines are obtained

from a Dischem Pharmacy (including Dischem Courier Pharmacy)










N/A




Members will receive a discount on contributions

if Public Hospitals are selected as their preferred

provider for in-hospital treatment and related

services

Efficiency Discount with Network

N/A N/A N/A

All day-to-day benefits paid from an Annual

Flexi Benefit at a provider within the Universal Network of Service

Providers

N/A N/A N/A

Overall Annual Limit (OAL)

Unlimited Unlimited Unlimited R1.5 million p/fR500 000 per incident

per year.Unlimited R1 million p/f

All Specialised Radiology including

MRI, CT and PET Scans

100% of AT. Unlimited. Pre-authorisation

required for all MRI and CT Scans. High

Resolution CT Scans/PET Scans subject to special medical motivation and pre-authorisation. No

benefit for unauthorised scans. No benefit for

screening purposes. The first R2 250 paid from

available MSA. Accumulates to threshold

100% of AT. Unlimited. Pre-authorisation required

for all MRI and CT Scans. High Resolution

CT Scans/PET Scans subject to special medical

motivation and pre-authorisation. No benefit for unauthorised scans. No benefit for screening purposes. The first R2

250 paid from available MSA.

Accumulates to threshold

100% of AT. Limited to R15 170 p.a. unless

otherwise pre-authorised. Pre-authorisation required



motivation and pre-authorisation. No benefit for unauthorised scans. No benefit for screening

purposes

100% of AT. Limited to R13 100 p.a. unless

otherwise pre-authorised. Pre-authorisation required



motivation and pre-authorisation. No benefit for unauthorised scans. No benefit for screening

purposes

20% co-payment and Individual Benefits apply except MRI and CT scans where the co-payment is

R1 000 per scan

100% of AT. Limited to} R15 170 p.a. Pre-

authorisation required for all MRI and CT

Scans. High Resolution CT Scans/PET Scans

subject to special medical motivation and pre-

authorisation. No benefit for unauthorised scans. No benefit for screening

purposes

100% AT. Subject to protocols and DSP.

Pre-authorisation required for all MRI and CT

Scans. High Resolution CT Scans/PET Scans

subject to special medical motivation and pre-

authorisation. No benefit for unauthorised scans. No benefit for screening purposes. Subject to OAL

2015 benefits


Hospitalisation

Pathology 100% of AT. Unlimited 100% of AT. Unlimited100% of AT. Limited to

R25 165 p/f unless otherwise pre-authorised

100% of AT. Limited to R19 550 p/f unless

otherwise pre-authorised. Subject to OAL

80% of AT.Limited to OAL

100% of AT. Limited to R25 170 p/f unless

otherwise pre-authorised

Subject to OAL, case management and protocols in DSP

Oncology including Chemotherapy

and Radiotherapy

Unlimited. Subject to pre-authorisation and protocols



Unlimited. Subject to pre-authorisation and

protocols. Limited to OAL

80% of ATSubject to OAL except

for PMBs


Unlimited. Subject to pre-authorisation and

protocols. Limited to OAL

Radial Keratotomy & Excimer Laser

Annual limit of R5 670 per eye, subject to pre-

authorisation and specific degree of myopia,

dioptres and astigmatism, or subject to optical limit







Subject to optical benefit80% of AT

Subject to optical benefit, pre-authorisation required

No benefit No benefit

Day-to-Day Cover (non hospital expenses)

Claims are paid initially from the Annual Medical Savings Account - MSA.

(20%). Once MSA become exhausted claims are paid from an Annual Flexi Benefit AFB, equal to 5% of contributions

where after the member is then liable for the Self Payment (SPG). During this period, claims will

accumulate to the Threshold Level at AT.

Once the Threshold Level is reached, specific above threshold benefits will be available up to a limit ofR7 525 p/b and R15 135

p/f with sub-limits

Claims are paid initially from the annual Medical Savings Account - MSA

(15%). Once MSA become exhausted claims are paid from an Annual Flexi Benefit AFB, equal to 5% of contributions

where after the member is then liable for the

Self Payment Gap (SPG). During this period, claims

will accumulate to the Threshold Level at AT.

Once the Threshold Level is reached, specific above threshold benefits will be available up to a limit of

R5 055 p/b andR10 110 p/f

with sub-limits

Benefits are paid from an annual Flexi-benefit

(AFB). If AFB is exhausted additional benefits are

available.AFB limits:P: R6 552A: R4 164C: R1 548

Total AFB = Family limit. No p/b limit

Max 3 child dependants

Benefits are paid from an Annual Flexi-benefit

(AFB). If AFB is exhausted additional benefits are

available.AFB limits:P: R4 944A: R3 096C: R1 236

Total AFB= Family limit. No p/b limit

Max 3 child dependants

Reimbursed on an 80% basis for doctors and healthcare providers.

Sub limits apply

Post operative rehab physio, occupational

therapy,Biokinesis, limited to

R5 750 p/f for14 Days

Pre-authorisation required.

PMBs only

If services are rendered by Universal Network

Providers, benefits will be paid at AT up to specified

limits. Some benefits subject to an Annual Flexi

Benefit (AFB):R2 532 p/bR3 780 p/f


Day-to-day benefits

General Practitioners

100% AT. Paid from MSA, AFB, SPG, after threshold unlimited.

Utilisation of a Universal Network GP will earn you 10% of payment amount into your AFB++ Account

100% AT. Paid from MSA, SPG, after

threshold unlimited. Utilisation of a Universal

Network GP will earn you 10% of payment amount into your AFB++ Account

100% AT. Paid from AFB first, thereafter

consultations (excluding procedures and materials) are unlimited. Utilisation of a Universal Network GP will earn you 10%

of payment amount into your AFB++ Account

100% AT. Paid from AFB first.

Consultations (excluding procedures and materials)

limited to M: 6 visits, M+1: 8 visits,

M+2: 10 visits, M+3+: 11 visits

Once the AFB is depleted, the balance of the

visits will be available. Utilisation of a Universal


Limit of R5 935 p/f. Combined limit with specialists. Payable at

80% of AT

No benefit

Unlimited at Universal Network GP. However Universal Care requires

clinical motivation to give an authorisation for GP visits, where more than 3 visits p/b are required. 2 out-of-area visits p/b.

Co-payment of 20%. Pay at point of service. limited

to R900 per event.

Specialists

200% AT. Initially paid from MSA, AFB, SPG, thereafter an above threshold benefit of R3 785 is available,

subject to overall above threshold limit. Utilisation

of a Universal Network GP will earn you 10%


100% AT. Initially paid from MSA, AFB, SPG, thereafter an above threshold benefit of R3 275 is available

subject to overall above threshold limit. Utilisation of a Universal Network GP will earn you 10%


100% AT Paid from AFB. Utilisation of a Universal Network GP will earn you 10%


100% AT Paid from AFB. Utilisation of a Universal Network GP will earn you 10%


Limit of R5 935 p/f. Combined limit with GPs.

Payable at 80% of ATNo benefit

100% AT. 2 visits p/b max 3 p/f per annum. Two additional

anti-natal visits per pregnancy. Subject to referral by a Universal Network GP and pre-authorisation of each

specialist visit. Referrals limited to specialists

located at DSP Network Hospitals only. Subject

to AFB.

Chronic Medicine

Subject to formulary.RP applies.

72 Conditions (27 CDL conditions

+ 45 Chronic) Unlimited for registered

CDL conditions. Paid from risk.

Non-CDL Chronic medication is paid from MSA, AFB and SPG first, limited to R10 090 p/b,

Max R15 150 p/f Above threshold benefits

limited to R3 785 and subject to overall above

threshold limit


63 Conditions (27 CDL conditions

+ 36 Chronic) Unlimited for registered

CDL conditions. Paid from risk.

Non-CDL Chronic medication is paid from

MSA, and SPG first limited to R7 570 p/b,

Max R12 625 p/f Above threshold benefits

limited to R2 520 and subject to overall above

threshold limit


46 Conditions (27 + 19 non-CDL Chronic) Limited to R3 785 p/b,

R5 670 p/f. Once benefit, depleted CDL medicines

are unlimited


Unlimited for the 27 Conditions.

Not subject to AFB

Non CDL, Max R9 645 per family per yearCDL/PMB Unlimited

through DSP, Formulary and reference pricing

apply


Unlimited for the 27 CDL Conditions. Not subject to AFB


27 CDL conditions - unlimited only if

prescribed by Universal Network Provider and

dispensed within Universal Network pharmacy or dispensing Universal Network doctor. Any

voluntary use of chronic medicine prescribed by out-of-network provider and any non-formulary

medicines are for members own account, unless pre-authorised by the medical advisor. PMB

rules apply

BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED EXCESS DIRECT AXIS NETWORX Day-to-day benefits

Acute medicines (Schedule 3 and higher)

Initially paid from MSA, AFB, SPG, thereafter an above threshold benefit

of R3 150 p/f is available, subject to overall above

threshold limit

Initially paid from MSA, AFB, SPG, thereafter an above threshold benefit


threshold limit

Paid from AFB Paid from AFB80% of AT. Max R6 600

per family per yearNo benefits

Unlimited if prescribed by a Universal Network GP,

or by a specialist, provided member was referred by a Universal Network GP. Subject to formulary. No cover for non-formulary

medicines unless otherwise pre-authorised. No cover in cases of voluntary use of non-DSPs, or voluntary use of specialist without referral by a Universal

Network GP

All Specialised Radiology including

MRI, CT and PET Scans

Subject to in-hospital Specialised radiology

benefit


benefit


benefit


benefit

1 incident per family per year. Co-payment of

R1 000No benefit

100% AT. PMBs only. Subject to pre-

authorisation and case management

Pathology

100% of AT. Initially paid from MSA, AFB, SPG, thereafter an above threshold benefit


threshold limit. Combined limit with radiology

Initially paid from MSA, AFB, SPG, thereafter an

above threshold benefit ofR2 520 p/f is available, subject to overall above

threshold limit. Combined limit with radiology

100% of AT. Paid from AFB subject to

scheme protocols

100% of AT. Limited to hospital basic

pathology limit of R19 550

80% AT. Maximum ofR4 280 per family per

year. Combined limit with radiology

No benefit

100% AT. Unlimited when clinically appropriate

within a Universal Network and subject to referral by a Universal

Network GP. Limited to list of codes. Subject to case management. No

benefit if not referred by a Network provider, or by a specialist following referral by a Universal Network GP (except when involuntary)

Conservative dentistry including consultations,

preventative care, fillings, extractions and

infection control

100% AT. Paid from MSA, AFB, SPG, after threshold unlimited. Utilisation of a Universal Network GP will earn you 10% of payment amount into your AFB++

Account

100% AT. Paid from MSA, AFB, SPG, after threshold unlimited. Utilisation of a Universal Network GP will earn you 10% of payment amount into your AFB++

Account

100% AT. Unlimited. Paid from AFB, thereafter unlimited. Utilisation of a Universal Network GP will earn you 10% of payment amount into your AFB++

Account

100% AT. Unlimited. Paid from AFB. thereafter unlimited. Utilisation of a Universal Network GP will earn you 10% of payment amount into your AFB++

Account

80% AT. Max R4 220 per family per family per year

No benefit100% of AT. Subject to

AFB, protocols apply

Specialised Dentistry, including Maxillo-

Facial and Oral surgery (In-and-out of hospital

combined limit)

100% AT. Paid from MSA and AFB, subject to a sub-limit of R14 575

p/b, including hospital & related costs.

Subject to protocols

100% AT - Paid from MSA and AFB, subject to a

sub-limit ofR9 530 p/b or R13 260 p/f, including hospital &

related costs. Subject to protocols

Paid from AFB. Subject to scheme protocols. Limited

to R6 360 p/b Implants: for members

account

Paid from AFB. Subject to scheme protocols. Limited

toR1 700 p/b Implants: for members

account

80% AT. Max R6 730 per family per family per year

No benefitNo benefit unless PMB.

Subject to protocols. Paid from AFB

Optical 100% SAOA Rates 100% SAOA Rates 100% SAOA Rates 100% SAOA Rates 80% of SAOA rates 100% SAOA Rates DSP Network only

Optometry visits

2 visits p/b per annum. Utilisation of a Universal


2 visits p/b per annum. Utilisation of a Universal


1 visit p/b per annum. Utilisation of a Universal


1 visit p/b per annum. Utilisation of a Universal


1 test payable at 80% to a limit of R390

No benefit1 visit p/b every second

year. Paid from AFB


Lenses, Frames and Contact Lenses

100% AT. Paid from MSA and AFB,

subject to a sub-limit ofR3 785 p/b.


100% AT. Paid from MSA and AFB, subject to a

sub-limit ofR3 030 p/b.


100% of AT. Paid from AFB, subject to a sub-limit of R1 700 p/b per annum

100% of AT. Paid from AFB, subject to a sub-lim-

it of R1 315 p/b and R3 795

p/f per annum

Single vision (incl. test) R770

Bifocal (incl. test) R1 170Multifocal (incl. test)

R1 550. Frames included in the lens benefit

No benefit

Clear plastic single vision (limited to R695) or

bi-focal lenses (limited to R1 113) every second year.

No benefit for contact lenses. Paid from AFB

FramesMax of R1 910 per frame - 1 frame p/b per annum -

included in lenses limit

Max of R1 270 per frame - 1 frame p/b per annum -

included in lenses limit

Max of R900 per frame - 1 frame p/b per annum - included in lenses limit

Max of R660 per frame - 1 frame p/b per annum - included in lenses limit

Included in lenses limit No benefitLimited range of frames

within DSP Network. Paid from AFB

Speech Therapists, Social Workers,

Podiatrists, Occupational Therapists,

Homeopaths & Naturopaths, Dieticians,

Chiropractors (x-rays excluded), Audiologist,

Physiotherapy and Biokinetics

(Subject to protocols)

100% of AT. Initially paid from MSA, AFB and SPG up to a collective limit of R6 295 p/f , thereafter an above threshold benefit for physiotherapy and bio kinetics of R2 530 is available. Subject to overall above threshold

limit

100% of AT. Initially paid from MSA, AFB and SPG up to a collective limit of R4 380 p/f, thereafter an above threshold benefit for physiotherapy and bio kinetics of R1 640 is available. Subject to overall above threshold

limit

100% of AT. Collective limit of

R 2 530 p/b. Paid from AFB

100% AT - Collective limit of

R1 645 p/b and R2 615 p/f. Paid from AFB

Physiotherapy, Chiropractor and

Biokineticist: Max R2 390 per family per year for all services Audiologist, Dietician, Occupational

therapist, Speech therapist: Max

R1 900 per family per year for all services

No benefitNo benefit unless PMB.

PMB rules apply

Wellness Benefits

Wellness, Lifestyle and Preventative Care (All benefits are paid from

risk, except where indicated differently)

Blood Pressure, Blood sugar, Cholesterol, BMI R155 p/b over the age of 18 only at DSP pharmacyRapid HIV tests 1 test p/b per annum

Prophylaxis Malaria as requiredFlu Vaccine, once per year p/b, limited to R80Tetanus vaccine, one injection when required

PSA (Prostate specific antigen) one test per male beneficiary over age 40. Quite smoking programme limited to R2 650 once a lifetime. Cost of programme will be refunded after the cotanine test to prove non-

smokingGlaucoma test one p/b per annum

Pap Smear one test per female over age of 18 per annumMammogram one test per female beneficiary over the age of 35 every second year

HPC (Cervical Cancer) vaccine One course (3 doses per registered schedule) per female beneficiary between12 and 18 years of age per life

Adult Pneumococcal Vaccine, PB over 60 and high risk members subject to pre-authorisation.Subject to protocols

Fitness Assessment and exercise prescription: Access to Universal Network Biokineticists for: annual fitness assessment, exercise prescription, regular monitoring. Strict Protocols apply

Nutritional assessment and healthy eating plan: Access to the Universal Network of dieticians for: annual assessment, healthy eating plan prescription, regular monitoring. Strict protocols apply

No benefit

Blood Pressure, Blood sugar, Cholesterol, BMI

R155 p/b over the age of 18 only at DSP pharmacy. Flu Vaccine,

once per year p/b, limited to R80

Newborn to Adult Benefit

Oral contraceptives, limited to R110 p/b per monthBaby wellness visit, two visits per annum for children between 4 weeks and 18 months at a DSP

Baby bag or voucher to value of R1 000. Childhood immunisations, applicable to children up to the age of 12 years, as per recommendation of the Department of Health

School readiness, 5 - 7 years oldPsychometric testing, 14 - 18 years

No benefit

Emotional Wellness Unlimited telephone counseling with referral for one on one counseling, to a limit of 3 sessions per annum

NEW!

Income Principal Adult Child Income Principal Adult Child

Pinnacle All Pinnacle ED All

Risk 3 536 2 751 985 Risk 2 904 2 258 816

Savings 876 684 240 Savings 876 684 240

Total 4 412 3 435 1 225 Total 3 780 2 942 1 056

Annual Savings 10 512 8 208 2 880 Annual Savings 10 512 8 208 2 880

Annual Flexi Benefit 2 388 1 860 660


Total Day to Day 12 900 10 068 3 540 Total Day to Day 12 900 10 068 3 540

Threshold (incl AFB)

14 208 11 043 3 857Threshold (incl

AFB)14 208 11 043 3 857

Self Payment GAP

1 308 975 317Self Payment

GAP1 308 975 317

Dynamix All Dynamix ED All

Risk 2 831 2 213 785 Risk 2 323 1 813 6 44

Savings 492 384 144 Savings 492 384 144

Total 3 323 2 597 929 Total 2 815 2 197 788

Annual savings 5 904 4 608 1 728 Annual Savings 5 904 4 608 1 728

Annual Flex benefit 1 800 1 416 504


Total Day to Day 7 704 6 024 2 232 Total Day to Day 7 704 6 024 2 232

Annual threshold 10 620 8 286 3 050Threshold (incl

AFB)10 620 8 286 3 050

Annual Self-payment GAP

2 916 2 262 818Self Payment

GAP2 916 2 262 818

Symmetry All Symmetry ED All

Risk 2 640 2 055 746 Risk 2 217 1 725 627

Annual Flexi benefit 6 552 4 164 1 548

Annual Flexi benefit 6 652 4 164 1 548

Income Principal Adult Child Income Principal Adult Child

Mumed

501 - 6 000

1 563 1 211 443

Mumed ED

0 -6 000

1 296 1 000 366

6 001 - 7 900

1 731 1 351 4936 001 - 7 900

1 429 1 105 408

7 901 - 15 000

1 886 1 471 5357 901 - 15 000

1 548 1 211 436

15 001+ 2 097 1 634 591 15 001+ 1 717 1 337 479

Mumed Network ED

501 - 7 900

1 212 946 346

7 901 - 15 000

1 321 1 030 376

15 001+ 1 469 1 143 415

Axis All 1 436 1 436 444 Axis ED All 1 077 1 077 339

NetworX

0 - 500 325 325 158

NetworX ED

0 - 500 310 306 168

501 - 4 000

523 497 183 501 - 4 000

353 346 174

4 001 - 5 000

540 513 189 4 001 - 6 000

452 429 215

5 001 - 6 000

646 613 227 6 001- 9 000

539 512 256

6 001 - 8000

676 643 237 9 001 - 10 000

571 543 272

8 001 - 9 000

769 732 270 10001+ 1 126 1 013 500

9 001 - 10 000

816 776 286

10001+ 1 501 1 351 526

Excess Direct R2 161 per family

All information relating to the 2015 CompCare Wellness Medical Scheme benefits and contributions are subject to formal approval by the Council for Medical Schemes. On joining the Scheme, all members will receive a detailed member brochure, as approved. The final registered Rules of the Scheme will apply.

*This brochure is a summary of the CompCare Wellness Medical Scheme.

2015 contributions

GlossaryPMB Prescribed Minimum BenefitMSA Medical Savings AccountCDL Chronic Disease ListP/F Per familyRP Reference PricingTTO To Take Out i.e. medicines taken out of hospital when dischargedAFB Annual Flexi Benefit

AFB++ Annual Flexi Benefit Plus Plus AccountSPG Self Payment GapP/B Per beneficiaryAT Agreed TariffDSP Designated Service ProviderTL Threshold LimitOTC Over The Counter Medicine

CompCare_2015_Product.pdf

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