Bonitas2016

THE BENEFITS

OF LIVING

HEALTHY

Your options for 2016

HEALTH Alexander Forbes Health is a licensed financial services provider (FSP 33471).

CMS registration number ORG 3064

Making the choice Bonitas updates for 2016 Your health, your

benefits

Focus on wellness

AIndustry few things to updates keep in mind

ALEXANDER FORBES

Your options for 2016 Bonitas updates for 2016

Focus on wellness

Important definitions

4

Are you considering changing your plan for 2016?

6

A summary of the changes

8

Why it’s important to review your plan every year

10

Choosing a medical aid plan that meets your needs

11

Chronic cover

12

Deductibles

13

Understanding the supplementary benefits

14

What contributes to medical aid increases?

18

Boncap hospital networks

19

GP and specialist networks

26

Pharmacy Direct

27

Details on Sanlam Reality

28

Embrace the benefits of living healthy

Industry updates

The role of health insurance in meeting your medical needs

33

Your rights and responsibilities

34

Prescribed minimum benefits explained

35

Downloads

Option change form

38

Contribution rates for 2016

38

While all reasonable care has been taken in compiling this communication, we have relied on the accuracy and completeness of the information made available to us by the respective schemes and product suppliers. Consequently we can’t accept any liability for any errors or omissions that may arise as a result of the reliance on such information.

Please note that the medical scheme changes are still subject to approval by the Council for Medical Schemes.

Alexander Forbes Health will keep you informed of further information or changes that we may become aware of.

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30

YOUR OPTIONS FOR 2016

BONITAS UPDATES FOR 2016

3

ALEXANDER FORBES

Designated service provider (DSP)

Important definitions

Any hospital or healthcare provider who has an agreement with Bonitas to provide treatment or services at a standard rate without any copayments.

Limits Some healthcare services, such as dentistry and optometry, have yearly limits on some medical aid options. It’s important for you to get to know the limits that apply to your chosen option. You can also track your use by checking your Bonitas claim statements.

Managed care programmes Bonitas provides a variety of programmes that coordinate care for everything from back problems to oncology.

These programmes include Medicine Management, Hospital Benefit Management, Oncology Benefit Management, Disease Management and the Bonitas Back Rehabilitation Programme.

Medicine list or formulary This is a list of approved chronic medicines that Bonitas covers.

Medical savings account This is an amount of money that gets set aside for you to pay for your day-to-day expenses.

Pharmacy advice therapy (PAT) Pharmacy advice therapy is an option you have to go to the pharmacist to recommend and dispense certain medicines without a doctor’s prescription.

Prescribed minimum benefit (PMB) conditions These are conditions which all medical aid schemes have to cover, as set out by the Council of Medical Schemes according to clinical guidelines. You may have to use a designated service provider (DSP) to treat PMB conditions.

Self-payment gap

Copayments

This is a temporary gap in cover when you run out of funds in your medical savings account (MSA) but have not yet reached your annual threshold. You’ll have to pay for your own day-to-day claims during this period. You should still submit your claims to Bonitas so that they know when to start paying from your threshold benefit, where applicable.

The payments you will need to make yourself in addition to Bonitas’s payments.

YourHealth portal

Aid for AIDS If you are HIV-positive, you must register with Aid for AIDS as soon as possible to use this benefit. Please call 0860 100 646.

Denis Denis is the preferred provider on Bonitas for dental benefits.

4

This is an online educational web and mobile health portal that gives Bonitas members access to a range of information and self-help tools. You need to register for this by visiting the Bonitas website www.bonitas.co.za.

YOUR OPTIONS FOR 2016

5

ALEXANDER FORBES

Are you considering changing your plan for 2016?

Medical schemes offer you the chance to change your medical aid plan at the end of every year. It’s a change that will directly influence your and your family’s health for the rest of the year. Take some time to understand the changes so that you have all the information you need to make your choice.

You don’t have to change your medical aid plan if you’re satisfied with your current plan and believe it will continue to meet your family’s needs throughout 2016, but please do take note of any changes for 2016 that apply to your plan.

To change your medical aid plan, complete a change form and send it to your human resources department by the required date.

Please note that if you don’t notify your human resources department of your plan choice before the deadline, you will stay on your current option and will be able to change your plan at the end of 2016.

Speak to your consultant Your Bonitas representative and Alexander Forbes Health consultant are available to guide you when making your choice. For other branch information please refer to page 37 of the magazine.

6

YOUR OPTIONS FOR 2016

Gap cover insurance Gap cover products are short-term insurance policies.

They pay in the difference between the rates that specialists charge and the rate your medical aid covers for in-hospital procedures, up to certain limits.

Even on your medical aid’s comprehensive option, you might still experience some gaps between the rate the scheme pays and the amount the service provider charges. Make sure you know if there are any potential gaps in your cover so that you can make an informed choice about the cover you need.

As an Alexander Forbes Health client, you can be assured of our unwavering commitment to help you enjoy the benefits of living health in 2016.

Our SERVE model drives the way we do business at Alexander Forbes. We strive to deliver Simple and Expert innovative solutions that build long-lasting Relationships founded on the Value of trust – all this in the service of Enriching your life by providing you with impactful service.

More information Follow #AF_Health on Twitter to keep your finger on the pulse of the medical scheme industry.

Bonitas website www.bonitas.co.za

Alexander Forbes Health Bonitas website Website: www.afhealth.co.za/bonitas

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ALEXANDER FORBES

A summary of the changes Option

Increase

Option

Increase

BonComprehensive

11.6%

Primary

10.5%

BonClassic

11.6%

BonEssential

10.5%

Standard

11.5%

BonCap

10.9%

BonSave

11.5%

New options Standard Select A traditional option with a savings account over and above the day-to-day benefits.

■■ Offers members unlimited hospitalisation at 100% of the Bonitas rate at network hospitals.

■■ Non-network hospital admissions will attract a 30% copayment.

Changes to existing options BonComprehensive 25% copayment in threshold has been removed.

■■ Medical savings have been reduced by 2%.

■■ Thresholds have increased by 27%, thereby increasing the self-payment gap significantly.

■■ Six chronic conditions have been added to the option.

These are Alzheimer’s disease (early onset), cystic fibrosis, deep-vein thrombosis, dermatomyositis, HIV and Aids, and psoriatic arthritis.

BonClassic ■■ Four chronic conditions have been removed, namely: bulimia nervosa, cystic fibrosis, motor neuron disease and thromboangitis obliterans.

BonFit A new-generation option that offers members unlimited hospitalisation at 100% of the Bonitas rate at network hospitals.

■■ A limited savings account for day-to-day benefits.

■■ Non-network hospital admissions will attract a 30% copayment.

Standard Out-of-hospital claims, excluding network GP consultations, will be paid from current savings available first. Once savings are depleted, claims will be paid from day-to-day benefits.

■■ A R5 000 copayment applies for hip and knee replacements where a non-ICPS provider is used.

Healthcare for Students This is a BonCap option for students only. Individuals must meet the following criteria to qualify: ■■ Be a full-time registered student ■■ Produce proof of registration or an acceptance letter with any institution of higher learning recognised by the department of education ■■ Applicants must be under the age of 28.

BonSave Savings account has been reduced slightly to 16%.

BonCap Contact lenses will be covered up to R750.

■■ Copayment for non-network hospital (except for emergencies) and failure to pre-authorise has increased to R5 650.

■■ Income bands have increased by an average of 7.1% with the exception of the first income band, which is the healthcare option for students.

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YOUR OPTIONS FOR 2016

Other benefit changes ■■ Cochlear implant cover has been increased to R250 000 per family per year on the BonComprehensive, BonClassic and Standard options.

■■ An education and coordination of care benefit will be introduced early in 2016.

■■ Electronic health record is an exciting online educational web and mobile health portal that will give members access to an abundance of resources to help them make better health choices and to be well informed. Members are required to register on the Bonitas website.

■■ Diabetic management care through the Centre for Diabetes and Endocrinology will be available on all options for members who have diabetes.

■■ Limits in general have been increased by inflation except for optical benefits.

■■ Copayments for 23 defined elective in-hospital procedures will range from R1 050 to R5 250 on the BonSave, Primary and BonEssential options.

■■ Laparoscopic nephrectomy has been removed from the copayment list on BonSave, Primary and BonEssential options.

Sanlam Reality wellness programme From January 2016 Bonitas members will have access to sign up for Sanlam Reality – a lifestyle, wellness, rewards and financial education programme. There will be three options available: ■■ Reality Health ■■ Reality Club ■■ Reality Core

Health Save up to 60% on monthly service fees at Planet Fitness or JustGym Wealth ■■ Wealth Sense – a guide to help in becoming financially fit ■■ Sanlam Product Benefits – generous discounts on insurance premiums, investment fees and free additional cover

Entertainment ■■ Nu Metro – pay R15 for a 2D movie ■■ Reality magazine – free quarterly lifestyle magazine ■■ Ster-Kinekor movies – buy one movie ticket, get one free ■■ Simfy – get six months free music streaming, thereafter 50% off

The monthly membership fees will be: Single member

Family

Reality Club

R35

–

Reality Core

R70

R100

Reality Health

R160

R200

While care has been taken in providing you with this information, scheme rules and benefits will always apply.

Reality Core is specifically tailored for Bonitas members to save money and achieve financial fitness. The following benefits will be available on the Reality Core option: Day-to-day savings ■■ Money Saver Card – saving money on day-to-day shopping (no card fee for three months) ■■ Personal Assistant – free help with quotes, directions and more Travel ■■ Mango flights – save up to 20% on local flights ■■ Protea Hotels – save up to 20% on accommodation ■■ Uber airport transfers – save up to 30% on airport transfers ■■ Tempest car hire – save up to 50% on car hire 9

ALEXANDER FORBES

Why it’s important to review your plan every year

The end of the year is a time when many people look forward to summer, sunshine and a welldeserved holiday. It’s also the time of the year when medical schemes announce their benefit changes and contribution increases. Reviewing your medical aid plan doesn’t have to be time-consuming or complicated. By simply having a conversation with your Alexander Forbes Health consultant, you can get a better understanding of what you’re covered for and make sure that over the next year you and your family will be on the right medical aid plan for your needs.

Changes to your health status could mean that your existing plan is no longer suitable for your healthcare needs. Risk tends to increase with age, so your medical aid should be adjusted as you move through the stages of life. Your chronic medication needs might change – even though all medical aid plans make provision for 27 chronic conditions, not all plans provide the same medication cover.

If you’re planning on undergoing a procedure or operation, do you know if there are sub-limits, copayments or deductibles on your plan? Do you know the rate at which your plan will reimburse your providers?

You might even be over-insured! In this case, you could save money by lowering your level of cover.

Life happens

It’s possible that you have both healthy and sick dependants in your family. By analysing your current option, your Alexander Forbes Health consultant can guide you to a solution.

A new addition to the family – or even planning a new addition in the near future – is a good reason to reassess your plan. Families with very young children fall into one of the highest medical aid claims categories. Premature labour is also a trend that is unfortunately on the rise.

Premature birth has consistently been ranked as one of the 10 most costly and frequent admissions in the industry over the past few years.

Most medical schemes have options with GP and hospital networks and regularly review and change these network listings. If you’re not aware of this, it could mean that you have to pay a penalty. It’s a good idea to familiarise yourself with the Boncap hospital networks and the accessibility of these networks.

Your consultant will complete a needs analysis of your requirements to find out exactly what type of cover you and your family need. Arrange to check in with your consultant before you go on holiday so that you can enjoy the benefits of living healthy in 2016.

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YOUR OPTIONS FOR 2016

Choosing a plan that meets your needs

It’s important to review your current medical aid cover at least once a year to make sure it will continue to meet your and your family’s healthcare needs.

Start by reviewing your own and your dependants’ use of healthcare services over the last two or three years, and consider what you might need in the near future.

Bonitas can provide you with a claims summary that will list all the claims you’ve made over a specific period of time.

This summary will show you exactly how much you and your dependants have spent – both in and out of hospital.

Please look at the benefits available in 2016 on your chosen plan, and compare these with the 2015 benefits on the same plan. If you experienced any shortfalls in 2015, it might mean that you need to look at an alternative plan for 2016, depending on your healthcare needs.

The next step is to look at how much it will cost to change your plan and to work your budget around your needs.

Remember that when changing your plan, you’ll need to make sure you’ve reviewed the changes to the option you’re considering.

Look for changes to:

■■ hospital reimbursement rates and sub-limits ■■ chronic condition and medication benefits ■■ copayments that apply in and out of hospital ■■ the amount that will be available for the year for your day-to-day expenses.

If you’d like to change your plan for 2016, you can contact Bonitas directly, or your Alexander Forbes Health consultant. Please remember to tell your employer about your new option if you’re currently on a company medical aid with Bonitas.

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ALEXANDER FORBES

Chronic cover BonSave

Bonitas covers lifethreatening conditions that require ongoing medication.

■■ 27 chronic conditions covered ■■ Restrictive formulary

A formulary is a medicine list.

Primary

■■ 27 chronic conditions covered ■■ Restrictive formulary

BonEssential

■■ 27 chronic conditions covered ■■ Restrictive formulary

BonComprehensive

A list of chronic medication covered under each option

■■ 60 chronic conditions covered ■■ Comprehensive and restrictive formulary

BonClassic

■■ 51 chronic conditions covered ■■ Restrictive formulary

Standard

Prescribed minimum benefits included Free delivery of chronic medication through Pharmacy Direct

■■ 44 chronic conditions covered ■■ Comprehensive and restrictive formulary

BonCap

■■ 27 chronic conditions covered ■■ Boncap medicine formulary

Standard Select

■■ 44 chronic conditions covered ■■ Comprehensive and restrictive formulary

Bonfit

■■ 27 chronic conditions covered ■■ Restrictive formulary

How to apply for the chronic medicine management (CMM) programme Telephonically

■■ Contact CMM on 0860 002 108.

■■ Email or fax the script to CMM. ■■ Once approved, a medicine access card confirming all approved conditions and medicine will be sent to you.

■■ Contact Pharmacy Direct for the delivery of your medicine.

Online ■■ ■■ ■■ ■■ ■■

Log on to the Bonitas website.

On the top right hand side of the webpage log in as a member.

Go to the Clinical information and select online chronic application.

Upload your chronic script.

Once approved, a medicine access card confirming all approved conditions and medicine will be sent to you.

■■ Contact Pharmacy Direct for the delivery of your medicine.

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YOUR OPTIONS FOR 2016

Deductibles Did you know?

The BonSave, BonFit, Primary and BonEssential plans have deductibles for certain procedures in hospital.

A deductible is an amount you must pay up front when admitted into hospital or a day clinic for particular procedures. You can’t claim that amount from the medical aid.

The following procedures attract a deductible: When you have to pay Planned hospital procedure

Amount due up front

■■ Colonoscopy ■■ Conservative back treatment ■■ Cystoscopy ■■ Facet joint injections ■■ Flexible sigmoidoscopy ■■ Functional nasal surgery ■■ Gastroscopy ■■ Hysteroscopy (not endometrial ablation) ■■ Myringotomy (grommets) ■■ Tonsillectomy and adenoidectomy (except prescribed minimum benefits) ■■ Umbilical hernia repair ■■ Varicose vein surgery

R1 050

■■ Arthroscopy ■■ Diagnostic laparoscopy ■■ Laparoscopic appendectomy ■■ Laparoscopic hysterectomy (except cancer and prescribed minimum benefits) ■■ Percutaneous radiofrequency ablations ■■ Percutaneous rhizotomies

R2 650

■■ Back surgery including spinal surgery ■■ Joint replacement (except prescribed minimum benefits) ■■ Laparoscopic pyeloplasty ■■ Laparoscopic radial prostatectomy ■■ Nissen fundoplication (reflux surgery)

R5 250

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ALEXANDER FORBES

Understanding

the supplementary benefits

Supplementary benefits are paid from risk and as such will not impact on your day-to-day benefits. Supplementary benefits can be used for authorised treatments in and out of hospital.

They’re available on the following options:

BonComprehensive Maternity care (per event)

Men’s health

Children’s health

General health

Cardiac health

Women’s health

■■ 12 antenatal consultations ■■ 2 × 2D scans ■■ 4 postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ 1 amniocentesis test ■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year

Wellness benefit

1 prostate PSA test between ages 55 and 69

1 full lipogram (20 years or older) per five-year cycle

1 assessment per beneficiary per year at a designated service provider, limited to one of the following: ■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist-to-hip ratio assessment

Elderly health

1 mammogram per two-year cycle between ages 50 and 74

Wellness extender benefit

Limited to R2 000 per family per year, subject to the registration and completion of the health risk assessment per beneficiary. Choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapist consultation ■■ Wearable devices (subject to approval) ■■ Smoking cessation programme (subject to approval)

■■ 1 lifetime pneumococcal vaccine for members 65 years or older ■■ 1 yearly faecal occult blood test for members between 50 and 75 years ■■ 1 lifetime bone density screening for female members 65 years or older

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■■ 1 thyroid stimulating hormones (TSA) test for infants below 1 month ■■ childhood immunisation according to the Expanded Program on Immunization (EPI) schedule

YOUR OPTIONS FOR 2016

BonClassic Maternity care (per event)

Women’s health

General health

Cardiac health

Wellness benefit

Wellness extender benefit

■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist-to-hip ratio assessment

■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapist consultation ■■ Wearable devices (subject to approval) ■■ Smoking cessation programme (subject to approval)

■■ 12 antenatal consultations ■■ 2 × 2D scans ■■ 4 postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ 1 amniocentesis test ■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year 1 assessment per beneficiary per year at a designated service provider, limited to one of the following:

■■ 1 mammogram per two-year cycle between ages 50 and 74 ■■ 1 pap smear per three-year cycle for female members between ages 21 and 65

1 full lipogram (20 years or older) per five-year cycle

Limited to R1 400 per family per year, subject to the registration and completion of the health risk assessment per beneficiary. Choose from the following:

Elderly health

■■ 1 lifetime pneumococcal vaccine for members 65 years or older ■■ 1 yearly faecal occult blood test for members between 50 and 75 years

Standard and Standard Select Maternity care (per event)

Infant paediatric benefit

Childhood illness benefit

General health

Cardiac health

Women’s health

Wellness benefit

Wellness extender benefit

1 assessment per beneficiary per year at a designated service provider, limited to one of the following:

Limited to R1 400 per family per year, subject to the registration and completion of the health risk assessment per beneficiary. Choose from the following:

■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist-to-hip ratio assessment

■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapist consultation ■■ Wearable devices (subject to approval) ■■ Smoking cessation programme (subject to approval)

■■ 12 antenatal consultations ■■ 2 × 2D scans ■■ 4 postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ 1 amniocentesis test ■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year

■■ 2 consultations per beneficiary under the age of 1 ■■ 2 consultations per beneficiary between ages 1 and 2

1 full lipogram (20 years or older) per five-year cycle

■■ 2 GP consultations per beneficiary between ages 2 and 12

■■ 1 mammogram per two-year cycle between ages 50 and 74 ■■ 1 pap smear per three-year cycle for female members between ages 21 and 65

Elderly health

■■ 1 lifetime pneumococcal vaccine for members 65 years or older ■■ 1 yearly faecal occult blood test for members between 50 and 75 years

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ALEXANDER FORBES

BonSave and BonFit

Maternity care (per event)

Infant paediatric benefit

General health

Women’s health

Wellness benefit

Wellness extender benefit

■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist-to-hip ratio assessment

■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapist consultation ■■ Wearable devices (subject to approval) ■■ Smoking cessation programme (subject to approval)

■■ 6 antenatal consultations ■■ 2 × 2D scans ■■ 4 postnatal consultations with a midwife ■■ R1 050 for antenatal classes ■■ 1 amniocentesis test ■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year

1 assessment per beneficiary per year at a designated service provider, limited to one of the following:

■■ 2 consultations per beneficiary under the age of 1 ■■ 2 consultations per beneficiary between ages 1 and 2

Childhood illness benefit

1 GP consultation per beneficiary between ages 2 and 12

1 pap smear per three-year cycle for female members between ages 21 and 65 Limited to R1 400 per family per year, subject to the registration and completion of the health risk assessment per beneficiary. Choose from the following:

Elderly health

■■ 1 lifetime pneumococcal vaccine for members 65 years or older ■■ 1 yearly faecal occult blood test for members between 50 and 75 years

Primary

Maternity care (per event)

Infant paediatric benefit

General health

Women’s health

Wellness benefit

Wellness extender benefit

■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist-to-hip ratio assessment

■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapist consultation ■■ Wearable devices (subject to approval) ■■ Smoking cessation programme (subject to approval)

■■ 6 antenatal consultations ■■ 2 × 2D scans ■■ 4 postnatal consultations with a midwife ■■ R1 050 for antenatal classes ■■ 1 amniocentesis test ■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year

1 assessment per beneficiary per year at a designated service provider, limited to one of the following:

Elderly health

■■ 1 consultation per beneficiary under the age of 1 ■■ 1 consultation per beneficiary between ages 1 and 2

■■ 1 GP consultation per beneficiary between ages 2 and 12

1 pap smear per three-year cycle for female members between ages 21 and 65 Limited to R1 000 per family per year, subject to the registration and completion of the health risk assessment per beneficiary. Choose from the following:

■■ 1 lifetime pneumococcal vaccine for members 65 years or older ■■ 1 yearly faecal occult blood test for members between 50 and 75 years

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Childhood illness benefit

YOUR OPTIONS FOR 2016

BonEssential

Maternity care (per event)

■■ 6 antenatal consultations ■■ 2 × 2D scans ■■ 4 postnatal consultations with a midwife ■■ 1 amniocentesis test

General health

Childhood illness benefit

Wellness benefit

Wellness extender benefit

■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist-to-hip ratio assessment

■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapist consultation ■■ Wearable devices (subject to approval) ■■ Smoking cessation programme (subject to approval)

■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year 1 assessment per beneficiary per year at a designated service provider, limited to one of the following:

1 GP consultation per beneficiary between ages 2 and 12

Limited to R700 per family per year, subject to the registration and completion of the health risk assessment per beneficiary. Choose from the following:

Elderly health

1 yearly faecal occult blood test for members between 50 and 75 years Boncap

Elderly health

1 yearly faecal occult blood test for members between 50 and 75 years

General health

■■ 1 HIV test per beneficiary per year ■■ 1 flu vaccine per beneficiary per year

17

ALEXANDER FORBES

What contributes to medical aid increases?

Alexander Forbes Health expects to see medical scheme increases continuing to be in excess of current consumer price inflation (CPI) rates for some time. This is both a South African and international trend.

We know that CPI is the basic measure of inflation in South Africa, and so it stands to reason that any medical inflation driver increasing in excess of current CPI rates would have a negative effect on medical inflation.

■■ Expenditure on private hospitals increased by 11.6%.

The Council for Medical Schemes recently released its 2014–2015 annual report.

Some of the major factors identified in the report that contributed to medical inflation over the period audited were detailed as follows:

■■ Payments to all specialists increased by 12%.

■■ Acute and chronic medication costs increased by 8.9%.

■■ Supplementary and allied health professional costs increased 14.5%.

■■ Total medical scheme non-healthcare expenditure rose by 7.1%.

■■ Expenditure on general practitioners increased by 7.6%.

■■ The use and ageing impact to larger schemes ranges from 1% to 2% and smaller schemes between 2% and 3%.

The following additional factors were also identified as having contributed to medical inflation:

■■ Use impact of factors like HIV and Aids, technological advances in treatment, diagnostics and medication as well as industry regulation ranges from 1% to 5%.

■■ Building reserves to the required statutory level of 25%.

■■ Need for benefit enhancements.

The escalating costs of hospitalisation and fees charged by both medical specialists and supplementary professionals are some of the primary factors driving medical inflation in South Africa today.

Disease burden and non-communicable diseases such as diabetes, high blood pressure and high cholesterol 18

are contributing to use increases as well as the cost of medicines to treat serious illnesses.

In this context, it’s important to understand that medical scheme increases are based on sound financial governance and not on profit motives.

YOUR OPTIONS FOR 2016

BonCap hospital networks BONCAP HOSPITAL NETWORK DAY CLINICS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province

Hospital Life Beacon Bay Hospital Life Isivivana Private Hospital Life Mercantile Private Hospital Life Queenstown Private Hospital

Private hospital

Eastern Cape

Life St Dominic's Hospital Life St Mary's Private Hospital Mthatha Private Hospital Netcare Cuyler Hospital Settlers Private Hospital

Day clinic

Free State

Bethlehem Medical Centre Life Rosepark Hospital Mediclinic Hoogland

Private hospital

Free State

Netcare Kroon Hospital Netcare Pelonomi Private Hospital St Helena Hospital Universitas Private Hospital

Free State Day clinic

Gauteng

Welkom Medical Centre Birchmed Surgical Centre Boksburg Medical & Dental Centre (Theatre) Botshilu Private Hospital – Shoshanguve Clinix Lesedi Private Hospital

Private hospital

Gauteng

Clinix Naledi-Nkanyezi Private Hospital Clinix Selby Park Hospital Clinix Tshepo-Themba Private Hospital Cure Day Clinics – Erasmuskloof Cure Day Clinics – Medkin

Day clinic

Gauteng

Fauchard Clinic Fordsburg Clinic Germiston Medical & Dental Centre

Private hospital

Gauteng

Day clinic

Gauteng

Private hospital

Gauteng

Lenmed Randfontein Private Hospital Leslie Williams Memorial Hospital Life Brooklyn Surgical Centre Life Carstenhof Clinic Life Eugene Marais Hospital Life Glynnwood Hospital

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ALEXANDER FORBES

BONCAP HOSPITAL NETWORK DAY CLINICS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province

Day clinic

Gauteng

Hospital Life Pretoria North Surgical Centre Life Robinson Private Hospital

Private hospital

Gauteng

Life Springs Parkland Clinic Life St Mary's Women's Clinic (Springsmed Maternity Home & Female Clinic) Life Suikerbosrand Clinic

Day clinic

Gauteng

Medgate Day Clinic

Private hospital

Gauteng

Mediclinic Legae Medicross Silverton Medical & Dental Centre (Theatre)

Day clinic

Gauteng

Medicross the Berg Mercidoc Day Clinic

Private hospital

Gauteng

Midvaal Private Hospital

Day clinic

Gauteng

Netcare Constantia Day Hospital Netcare Garden City Hospital Netcare Jakaranda Hospital

Private hospital

Gauteng

Netcare Krugersdorp Hospital Netcare Montana Private Hospital Netcare Mulbarton Hospital

Day clinic

Gauteng

Netcare Protea Day Clinic Netcare Rand Hospital

Private hospital

Gauteng

Netcare Unitas Hospital

Day clinic

Gauteng

South Day Clinic

Private hospital

Gauteng

Day clinic

KwaZulu-Natal

Netcare Vaalpark Hospital Zamokuhle Private Hospital Zuid-Afrikaans Hospitaal Bluff Medical & Dental Centre City Hospital Ltd Durdoc Clinic Division of the Durban Anaesthetic Clinic (Pty) Ltd Private hospital

KwaZulu-Natal

Lenmed La Verna Hospital Life Chatsmed Garden Hospital Life Empangeni Garden Clinic

Day clinic

KwaZulu-Natal

Medicross Malvern Medical & Dental Centre (Theatre)

Private clinic

KwaZulu-Natal

Medicross Pinetown Medical & Dental Centre (Theatre) Netcare St Anne's Hospital

Private hospital

KwaZulu-Natal

Netcare St Augustine's Hospital Netcare the Bay Hospital

Day clinic

KwaZulu-Natal

Shelly Beach Day Clinic Westridge Surgical Clinix Phalaborwa Private Hospital

Private hospital

Limpopo

Mediclinic Limpopo Mediclinic Thabazimbi

20

YOUR OPTIONS FOR 2016

BONCAP HOSPITAL NETWORK DAY CLINICS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province

Hospital

Private hospital

Limpopo

Mediclinic Tzaneen

Day clinic

Mpumalanga

Emalahleni Day Hospital

Private hospital

Mpumalanga

Kiaat Private Hospital

Day clinic

Mpumalanga

Kriel Medical Centre Life Cosmos Hospital

Mpumalanga

Life Midmed Hospital Mediclinic Barberton Mediclinic Ermelo Amandelbult

Private hospital

Clinix Itokolle-Victoria Private Hospital North West

Duff Scott Hospital (Pty) Ltd Life Anncron Clinic Life Peglerae Hospital Mediclinic Brits

Day clinic

North West

Medicross Potchefstroom Baby Clinic Netcare Ferncrest Hospital

North West Private hospital

Rustenburg Medi-Care Centre Rustenburg Platinum Mines Hospital (Rustenburg Section) Vryburg Private Hospital Mediclinic Gariep

Northern Cape

Mediclinic Kathu Mediclinic Upington

Day clinic

Western Cape

Cure Day Clinic–Stephen's Paarl Life Bay View Private Hospital Life West Coast Private Hospital

Private hospital

Western Cape

Mediclinic Paarl Mediclinic Westfleur Mediclinic Worcester Medicross Langeberg Medical & Dental Centre

Day clinic

Western Cape

Medicross Parow Medical & Dental Centre (Theatre) Medicross Tokai Family Medical & Dental Centre Melomed Gatesville Melomed Mitchells Plain

Private hospital

Western Cape

Netcare Kuils River Hospital Netcare N1 City Hospital UCT Private Academic Hospital

Private hospital (B-status) Private hospital (A-status)

Gauteng

Arwyp Medical Centre

Gauteng

Clinix Bothshelong–Empilweni Private Hospital (Pty) Ltd

Kwazulu-Natal

Newcastle Private Hospital

North-West

Rustenburg Platinum Mines 21

ALEXANDER FORBES

STANDARD SELECT ACUTE CLINICS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province

Hospital name Life Beacon Bay Hospital Life Queenstown Private Hospital Life St Dominic's Hospital

Eastern Cape

Life St James Hospital Life St Mary's Private Hospital Life Isivivana Private Hospital Life Mercantile Private Hospital Life St George's Hospital

Free State

Life Rosepark Hospital Bedford Gardens Private Hospital Genesis Clinic – Saxonwold Life Brenthurst Clinic Life Carstenhof Clinic Life Fourways Hospital Life Robinson Private Hospital Life Wilgeheuwel Hospital Life Flora Clinic Netcare Bougainville Private Hospital

Gauteng

Netcare Femina Hospital Netcare Jakaranda Hospital Netcare Montana Private Hospital Netcare Moot General Hospital Netcare Unitas Hospital Netcare Clinton Hospital

Acute hospital

Netcare Linmed Hospital Netcare Sunward Park Hospital Netcare Union Hospital Life Suikerbosrand Clinic Netcare Vaalpark Netcare Kingsway Hospital Netcare Kokstad Private Hospital KwaZulu-Natal

Netcare Parklands Hospital Netcare St Anne's Hospital Netcare St Augustine's Hospital Netcare The Bay Hospital

Limpopo

Netcare Pholoso Life Cosmos Hospital

Mpumalanga

Life Midmed Hospital Life Piet Retief Hospital

North West

Life Anncron Clinic Life Peglerae Hospital Ceres Private Hospital Netcare Blaauwberg Hospital Netcare Christiaan Barnard Memorial Hospital

Western Cape

Netcare Kuils River Hospital Netcare N1 City Hospital Life Bay View Private Hospital Life Knysna Private Hospital Life West Coast Private Hospital

22

YOUR OPTIONS FOR 2016

STANDARD SELECT DAY CLINICS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province

Hospital

Eastern Cape

Medical Forum Theatre Bethlehem Medical Centre Citymed Day Clinic Cure Day Clinics – Bloemfontein Welkom Medical Centre Birchmed Surgical Centre Boksburg Medical & Dental Centre (Theatre) Centre Of Advanced Medicine Cure Day Clinics – Erasmuskloof Cure Day Clinics – Medkin Cure Day Clinics – Midstream Fauchard Clinic Fordsburg Clinic Germiston Medical & Dental Centre Intercare Day Hospital Hazeldean Intercare Day Hospital Irene Intercare Sandton Day Hospital Karibu Day Clinic Life Brooklyn Surgical Centre Life Pretoria North Surgical Centre Mayo Clinic Medgate Day Clinic Medicross Constantia Park – Day Surgery Medicross Silverton Medical & Dental Centre (Theatre) Medicross the Berg Mercidoc Day Clinic Netcare Constantia Day Hospital Bluff Medical & Dental Centre Care Clinic (Westville) KZN Day Clinic Medicross Malvern Medical & Dental Centre (Theatre) Medicross Pinetown Medical & Dental Centre (Theatre) Shelly Beach Day Clinic Westridge Surgical Emalahleni Day Hospital Kriel Medical Centre Mediclinic Limpopo Day Clinic Medicross Potchefstroom Baby Clinic Advanced Durbanville Surgical Centre Cure Day Clinics – Somerset West Cango Medicentre Cure Day Clinic – Stephen's Paarl Drs Aevitas Ingelyf George Surgical Centre Intercare Day Hospital – Century City Life Kingsbury Hospital Life Sport Science Orthopaedic Surgical Day Centre Mediclinic Durbanville Day Hospital Medicross Langeberg Medical & Dental Centre Medicross Parow Medical & Dental Centre (Theatre) Medicross Tokai Family Medical & Dental Centre Monte Vista Kliniek The Surgical Institute Wesfleur Private Clinic

Free State

Gauteng

Day clinic

KwaZulu-Natal

Mpumalanga Limpopo North West

Western Cape

23

ALEXANDER FORBES

BONFIT ACUTE HOSPITALS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province

Eastern Cape

Free State

Gauteng

Acute hospital

KwaZulu-Natal

Limpopo Mpumalanga

North West

Western Cape

24

Hospital name Life Beacon Bay Hospital Life Isivivana Private Hospital Life Mercantile Private Hospital Life Queenstown Private Hospital Life St Dominic's Hospital Life St George's Hospital Life St James Hospital Life St Mary's Private Hospital Life Rosepark Hospital Bedford Gardens Private Hospital Genesis Clinic – Saxonwold Life Brenthurst Clinic Life Carstenhof Clinic Life Flora Clinic Life Fourways Hospital Life Robinson Private Hospital Life Suikerbosrand Clinic Life Wilgeheuwel Hospital Netcare Bougainville Private Hospital Netcare Clinton Hospital Netcare Femina Hospital Netcare Jakaranda Hospital Netcare Linmed Hospital Netcare Montana Private Hospital Netcare Moot General Hospital Netcare Sunward Park Hospital Netcare Union Hospital Netcare Unitas Hospital Vaalpark Hospital Netcare Kingsway Hospital Netcare Kokstad Private Hospital Netcare Parklands Hospital Netcare St Anne's Hospital Netcare St Augustine's Hospital Netcare The Bay Hospital Netcare Pholoso Life Cosmos Hospital Life Midmed Hospital Life Piet Retief Hospital Life Anncron Clinic Life Peglerae Hospital Ceres Private Hospital Life Bay View Private Hospital Life Kingsbury Hospital Life Knysna Private Hospital Life West Coast Private Hospital Netcare Blaauwberg Hospital Netcare Christiaan Barnard Memorial Hospital Netcare Kuils River Hospital Netcare N1 City Hospital

YOUR OPTIONS FOR 2016

BONFIT DAY CLINICS *Disclaimer: Subject to approval by Council for Medical Schemes.

This list is subject to change, therefore please refer to the website.

Type

Province Eastern Cape Free State

Gauteng

Day clinic

KwaZulu-Natal

Limpopo Mpumalanga North West

Western Cape

Hospital name Medical Forum Theatre Bethlehem Medical Centre Citymed Day Clinic Cure Day Clinics – Bloemfontein Welkom Medical Centre Birchmed Surgical Centre Boksburg Medical & Dental Centre (Theatre) Centre Of Advanced Medicine Cure Day Clinics – Erasmuskloof Cure Day Clinics – Medkin Cure Day Clinics – Midstream Fauchard Clinic Fordsburg Clinic Germiston Medical & Dental Centre Intercare Day Hospital Hazeldean Intercare Day Hospital Irene Intercare Sandton Day Hospital Karibu Day Clinic Life Brooklyn Surgical Centre Life Pretoria North Surgical Centre Mayo Clinic Medgate Day Clinic Medicross Constantia Park – Day Surgery Medicross Silverton Medical & Dental Centre (Theatre) Medicross the Berg Mercidoc Day Clinic Netcare Constantia Day Hospital Bluff Medical & Dental Centre Care Clinic (Westville) KZN Day Clinic Medicross Malvern Medical & Dental Centre (Theatre) Medicross Pinetown Medical & Dental Centre (Theatre) Shelly Beach Day Clinic Westridge Surgical Mediclinic Limpopo Day Clinic Emalahleni Day Hospital Kriel Medical Centre Medicross Potchefstroom Baby Clinic Advanced Durbanville Surgical Centre Cango Medicentre Cure Day Clinic – Stephen's Paarl Cure Day Clinics – Somerset West Drs Aevitas Ingelyf George Surgical Centre Intercare Day Hospital - Century City Life Sport Sc ience Orthopaedic Surgical Day Centre Mediclinic Durbanville Day Hospital Medicross Langeberg Medical & Dental Centre Medicross Parow Medical & Dental Centre (Theatre) Medicross Tokai Family Medical & Dental Centre Monte Vista Kliniek The Surgical Institute Wesfleur Private Clinic 25

ALEXANDER FORBES

GP

and specialist networks

Bonitas Medical Fund is always investigating new ways to help you save money while receiving the best healthcare services available today.

The GP network What is it?

The GP network will provide you with access to over 7 000 general practitioners at a fixed rate. This will put healthcare back in your hands, giving you more control over your health and medical expenses.

Why was it introduced?

Bonitas noticed thousands of members visiting many different GPs for different reasons. This resulted in duplicate testing, duplicate costs and unnecessary visits – and most notably of all an increase in out-of-pocket expenses.

How does it work?

All Bonitas members can make use of the Bonitas GP network of doctors. Choosing to visit a GP in the network provides you with the guarantee that you won’t be charged more than the Bonitas tariff.

26

The specialist network ■■ Access to over 2 000 specialists nationally.

■■ Access to specialist services at a negotiated tariff for both in-hospital and out-of-hospital costs.

■■ Claims will be paid in full, meaning you won’t have to pay any shortfalls.

■■ If you have a prescribed minimum benefit condition and have reached the limit on your day-to-day benefit, you can continue to consult specialists within the network without incurring any copayments.

To check if your GP or specialist is on the Bonitas network, visit the Bonitas website or call 0860 002 108.

YOUR OPTIONS FOR 2016

Pharmacy Direct Has the chronic medicine management (CMM) at Bonitas approved your chronic conditions and medication?

IF YES

complete the Pharmacy Direct application form (available on the Bonitas website) or contact the call centre on 086 002 7800.

STEP

1

STEP

2

Fax the application form and a copy of the script to Pharmacy Direct on 086 611 4000 or 086 611 4001 or 086 611 4002 or 086 611 4003.

IF NO

please contact Bonitas CMM on 0860 002 108 to register.

Once received and approved, Pharmacy Direct will deliver your medication to the address provided.

STEP

3

Please remember to submit an updated script every six months.

Contact Pharmacy Direct Practice number: 0126225 Fax: 086 611 4000 or 1 or 2 or 3 Queries: 0860 027 800

6

MONTHS

Aid for Aids: 0860 103 810 Switchboard: +27 (0)12 643 3000 Email: care@pharmacydirect.co.za Website: www.pharmcydirect.co.za

27

ALEXANDER FORBES

Details

on Sanlam Reality

Sanlam Reality is a lifestyle, wellness, rewards and financial education programme for Bonitas members in 2016.

im nefits a The be u save yo to help el on trav nt, y e n o m e tertainm and en our ey improv d give you an l health nancia fi le b a valu tips. fitness

MONEY SAVER CARD Earn up to 10% back on your monthly spend.

WEALTH SENSE

This is an online financial platform to help you get financially fit.

Single member

Family

Reality Club

R35

–

Reality Core

R70

R100

R160

R200

Reality Health

To find out more about Sanlam Reality, visit the website.

28

FOCUS ON WELLNESS 29

ALEXANDER FORBES

Embrace the benefits of living healthy

It’s important to be financially fit, but it’s just as important to be healthy to enjoy your life to the fullest.

5 STEP

1

These five simple steps are all you need to improve your health now and into the future.

Stop smoking Cigarettes contain more than 4 000 toxins, many of which have been proven to increase the likelihood of cancer. The tar found in cigarettes lines the airways, causing lung diseases and cancers. In fact, 90% of lung cancer cases are related to smoking.

HEALTH BITE

STEP

2

Cut down on alcohol Drinking excessive amounts of alcohol over a long period of time can lead to liver disease, heart disease and several other potentially life-threatening medical conditions. Drink alcohol in moderation and be selective about the type of alcohol you consume.

HEALTH BITE

STEP

3

Mayo Clinic indicates that red wine contains antioxidants and resveratrol, which are both good for the heart and for raising good fats (HDL). A glass of red wine with your meal is adequate and healthy.

Exercise Regular exercise (at least three to five times a week) that raises your heart rate for 30 minutes is beneficial to your health. Walking, swimming, jogging or bicycle riding are all good habits to cultivate. These fitness activities also produce ‘happy’ hormones called endorphins, which reduce stress and lift your mood. Remember to allow your body a rest day once or twice a week to give your muscles a chance to recover.

HEALTH BITE 30

A study conducted on over 34 000 medical doctors, published in the British Medical Journal showed that quitting smoking at age 40 adds nine years to your life, quitting at age 50 adds six years to your life, and quitting at age 60 adds three years to your life.

Step into the light! Being out in the sunshine produces vitamin D and improves the absorption of calcium. Just remember to put on sunscreen.

YOUR OPTIONS FOR 2016

STEP

4

Eat healthy foods Eating the right food helps build the immune system, fight cancer-causing cells, maximise lean muscle mass and reduce fat. A healthy and balanced diet requires eating a variety of vegetables, fruit, milk, nuts and other food groups. Each of these contains different nutrients and elements such as vitamins A, C and E, selenium, fibre, iron, magnesium and calcium which help keep your immunity strong. You can also take vitamin and mineral supplements if your diet is not fully balanced. Remember that reducing your intake of salt and bad fats will also improve your health.

HEALTH BITE

STEP

5

Don’t skip breakfast.

Eat five small meals a day rather than three big meals.

Drink at least eight glasses of water daily.

Increase fibre and roughage.

Eat supper at least two hours before bed to allow for proper digestion.

Go for your annual medical check-up There are several ‘silent’ diseases which, if not picked up through routine check-ups before any symptoms appear, will only be evident when there are severe complications. By then it might be too late to heal or manage them.

It’s a good idea to visit your family doctor and dentist at least once a year for a general checkup that includes testing for: ■ hypertension ■ diabetes mellitus ■ high cholesterol ■ cancer.

Your doctor should test your thyroid function, do a pap smear if you’re female or a prostate exam if you’re male, check for breast and skin cancer, and any other routine tests appropriate for your age. Your family doctor will need a detailed history to recommend the most appropriate assessments to manage any treatable medical conditions proactively.

HEALTH BITE

From the age of 40, women should have a mammogram once a year along with other screening assessments. A colonoscopy may be recommended for some patients over 50 years to identify polyps and other risk factors for colon cancer.

Cultivating these healthy habits early on improves the chances of early detection and treatment of diseases, which will increase longevity and improve your quality of life.

Dr Lerato Motshudi Alexander Forbes Health

31

ALEXANDER FORBES

INDUSTRY

UPDATES 32

YOUR OPTIONS FOR 2016

The role

of health insurance in meeting your medical needs We have a constitutional right to insure ourselves against any financial risk, but people are often unaware of the subtle differences between a health insurance product and a medical aid scheme. Many believe that a health insurance policy offers the same protection as medical aid for major medical events, but in fact the protection offered by health insurance is only partial and conditional.

South Africa’s health sector doesn’t currently have any regulations in place to govern the tariffs charged to patients by healthcare professionals, so private practitioners can determine their own fees. This practice often results in a significant gap, reaching as much as 450% to 500% between what is charged by private specialist doctors and what is reimbursed by medical aid schemes.

It’s this uncertainty about what medical bills may arise in the future and what shortfalls may occur for a medical aid member that has resulted in strong public support for health insurance cover, specifically hospital cash plans and gap cover products.

A gap cover policy is a specific type of short-term health insurance designed to protect medical aid members from costs not covered by medical aid benefits. It pays the difference between the actual fees charged by health professionals such as anaesthetists, surgeons, other specialists or GPs and the medical aid rate, for medical and surgical procedures done in-hospital only.

A hospital cash plan targets non-medical aid members who want to insure themselves against using public hospitals and services. The policies are much more affordable than medical aid cover and pay a fixed rate for each day spent in hospital. The benefit usually becomes payable only after the second or third day of hospitalisation. Day procedures for conditions like a burst appendix, which don’t require an overnight stay, might not be covered.

What is health insurance?

A health insurance policy is a contract sold by an insurance company to an individual according to the Short-term Insurance Act, and is subject to regulatory supervision by the Financial Services Board (FSB).

The policy promises to pay for certain stated or fixed benefits when the policyholder is ill or injured. The policyholder pays a monthly premium which is directly related to their age, health status and income. For example, a policyholder who is a smoker and plays a dangerous sport as a hobby (such as sky diving) would pay a significantly higher premium for the same level of cover than a non-smoker of similar age who doesn’t play a dangerous sport. Specific types of exclusions may also be built into a policy, such as a maximum age at entry, which excludes older people for cover (particularly retirees).

The regulations The draft demarcation regulations published by National Treasury specify the types of health insurance policies that are accepted under the Short-term Insurance Act. The intention of the regulations is to create a clear demarcation between health insurance and medical aid business. The aim is to ensure that the design, marketing and sale of health insurance policies complement medical aid schemes without undermining the social solidarity principles of pooled contributions and open membership, while at the same time serving the needs of individuals who need extra financial protection against high medical expenses.

33

ALEXANDER FORBES

Your

rights and responsibilities

As a medical aid member, you have the right to: ■■ belong to one medical aid at a time ■■ continue your membership until death (known as guaranteed cover) ■■ expect the trustees of your medical aid to act in the members’ best interests at all times ■■ have your medical records kept safe and confidential (POPI Act) ■■ receive payment in full – without copayment for the prescribed minimum benefits (PMBs) from the risk benefits of the medical aid and without paying from your day-to-day benefits ■■ receive quick payment of claims within 30 days of receipt of a claim ■■ change your benefit option every year ■■ a copy of the registered scheme rules ■■ a copy of the prescribed minimum benefits (PMBs) treatment protocol and drug formulary for your registered chronic condition ■■ receive written proof of membership and a certificate of membership on resignation from the medical aid ■■ lodge a complaint or dispute – first with the medical aid directly, then with their dispute committee if you’re not satisfied with the response, and lastly with the Registrar’s office at the Council for Medical Schemes.

As a medical aid member, you have a responsibility to: ■■ do your research before choosing a medical aid option to make sure the medical aid is in good financial health and that good corporate governance is in place (an accredited healthcare broker can help you get clarity on these matters) ■■ provide full medical disclosure on admission to membership ■■ choose a benefit option that meets your medical needs and affordability ■■ be aware of how your benefits work, especially the prescribed minimum benefits (PMBs) ■■ not commit a fraudulent act or claim against the medical aid, for example buying sunglasses or other nonmedical items, or lending your membership card to someone else ■■ pay contributions promptly within three days of the due date ■■ submit claims within four months of the date of service or treatment ■■ abide by the rules of the medical aid you belong to ■■ take part in your medical aid scheme’s annual general meeting where members voice opinions, ask questions and present motions ■■ nominate new trustees who have the right skills and experience to serve on the board of trustees.

34

YOUR OPTIONS FOR 2016

Prescribed

minimum benefits explained Prescribed minimum benefits (PMBs) are a basket of benefits that all medical aid members are entitled to, no matter what plan they choose. The PMBs provide fairness and ensure that, regardless of health or age, all members are treated equally and have a safety net of access to a basic level of healthcare cover.

The basket of care must provide for the diagnosis, treatment and ongoing care costs for:

■■ a limited set of 270 conditions (called the diagnostic treatment pairs) ■■ a list of 27 chronic illness conditions (referred to as the chronic disease list or CDL) ■■ any emergency condition

PMBs can be divided into 15 categories: PMB category

Examples

Brain and nervous system

Stroke, brain tumour, epilepsy, fractures of the skull, Gillian–Barré, meningitis, encephalitis and paralysis

Eyes

Glaucoma, treatable cancer of the eye, and retinal detachment

Ears, nose, mouth and throat

Cancer of oral cavity, pharynx, nose, ear and larynx. Most obstructions of the upper airway

Respiratory system

Pneumonia, acute asthma and other respiratory distress syndromes

Heart and vasculature (blood vessels)

Heart attacks, acute rheumatic fever, hypertension

Gastro-intestinal system

Appendicitis, acute diverticulitis of the colon, uncomplicated hernias under the age of 18

Liver, pancreas and spleen

Gallstones with cholecystitis, necrosis or cancer of the liver, and acute pancreatitis

Musculoskeletal system Treatable cancer of the bones, chronic osteomyelitis (infection in a bone), fracture (muscles and bones), trauma of the hip, open fractures and crush injuries neurological outcome scale (NOS) Skin and breast

Treatable breast and skin cancer

Endocrine, metabolic and nutritional

Disorders of the parathyroid gland and acute thyroiditis

Urinary and male genital system

End-stage kidney disease, treatable cancers, abscess on the prostrate, ruptured bladder

Female reproductive system

Ectopic pregnancy, cancer of the cervix, ovaries and uterus

Pregnancy and childbirth

Antenatal and obstetric care requiring hospitalisation, including delivery

Haematological, infectious and miscellaneous systemic conditions

Syphilis, leukaemia, malaria, HIV and Aids, and TB

Mental illness

Acute stress disorder, anorexia, bipolar, and treatable dementias

Chronic illness conditions (27 in total)

Asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disorder, chronic renal disease, coronary artery disease, Crohn’s disease, diabetes insipidus, diabetes mellitus type 1, diabetes mellitus type 2, dysrhythmias, epilepsy, glaucoma, haemophilia, HIV and Aids, hyperlipidemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, ulcerative colitis 35

ALEXANDER FORBES

How do the PMBs differ from other medical aid benefits?

The regulations laid out by the Medical Schemes Act define how medical aids must pay for PMBs: ■■ Medical schemes have to pay for PMBs in full and without a copayment from the risk benefits of the medical scheme, and not from a member’s day-to-day benefits.

■■ The public sector is the benchmark for minimum level of care, but medical aid schemes cannot simply nominate the state as the provider. They must ensure that the state facility in question has the capacity to deliver.

How do medical schemes manage the cost of PMBs? Although medical schemes must pay in full for PMBs, they’re allowed to stipulate that costs will only be paid in full and without copayment if members make use of designated service providers (DSPs). These are healthcare providers (facilities, professional groups and individual professionals) selected by the medical aid as preferred service providers or first-choice service providers. They have a payment agreement with the

scheme. DSPs include hospitals, pharmacies, doctors and specialists. If a member voluntarily chooses to use a non-DSP, the medical aid is not obliged to pay the full cost of treatment and may charge the member a copayment.

However, if a member obtains a service from a non-DSP involuntarily because of an emergency, the medical aid is obliged to fund the treatment in full.

What qualifies as emergency use of a non-DSP? Primary reasons for involuntary use of a non-DSP: ■■ If the service required by the member is not available at all, or without unreasonable delay from the DSP. This generally applies where the state is the nominated DSP and medical equipment or supplies are not readily available.

■■ If the DSP is not within reasonable distance from the member’s residence or place of work. The distance is not defined in law and each medical aid scheme applies its own interpretation.

■■ If immediate medical or surgical treatment is required, where failure to provide such treatment would result in serious bodily impairment, dysfunction or even death.

An example would be a serious motor vehicle accident.

What other measures do medical aid schemes take to control PMB costs?

The cost of PMBs is becoming very expensive for medical aid schemes to provide and very expensive for members to afford.

According to the Council for Medical Schemes, the most prevalent PMB chronic conditions identified among medical aid beneficiaries are high blood pressure, high cholesterol, diabetes mellitus type 2, and asthma.

Given the high cost of PBMs and the impact on affordability, medical aid schemes try to manage the costs downward through various managed-care interventions. This includes nominating contracted DSPs, the use of specific coding on claims invoices for PMB identification, treatment protocols or plans, and medication formularies.

In general, medical aid schemes will only make a payment for a PMB if the healthcare provider uses an

36

ICD-10 diagnostic code that identifies the claim as a PMB for the ‘payment in full’ requirement.

Treatment protocols include the minimum medications, types of tests, investigations and number of consultations for each chronic condition in the PMB basket. A medication formulary is a restricted list of drugs approved by the medical aid for each chronic condition.

To avoid a copayment, members need to follow the prescribed treatment plan and use the formulary drugs.

However, if a member needs more services than are provided for in the treatment protocol, or if a drug on the formulary is ineffective or might cause an adverse medical reaction, the member can appeal to their medical aid. The appeal process might include a motivation from the treating doctor that explains the clinical reasons for additional services or drug substitutions.

YOUR OPTIONS FOR 2016

Contact information Head office – Sandton Alexander Forbes, 115 West Street, Sandton PO Box 787240, Sandton, 2146 Telephone: +27 (0)11 269 0000 Fax: +27 (0)11 263 1111

Stellenbosch 40 Dorp Street, Stellenbosch PO Box 501, Stellenbosch, 7599 Telephone: +27 (0)21 809 3600 Fax: +27 (0)21 886 4432

Pretoria Alexander Forbes House, 189 Clark Street, Brooklyn, Pretoria PO Box 2435, Pretoria, 0001 Telephone: +27 (0)12 452 7111 Fax: +27 (0)12 452 7715

Durban Alexander Forbes Place, 10 Torsvale Crescent, Torsvale Park, La Lucia Ridge Office Estate, La Lucia PO Box 782, Umhlanga Rocks, 4320 Telephone: +27 (0)31 573 8000 Fax: +27 (0)31 573 8311

Cape Town Block A, The Boulevard, Searle Street, Woodstock, Cape Town PO Box 253, Cape Town, 8000 Telephone: +27 (0)21 401 9300 Fax: +27 (0)21 415 5580

East London 1st Floor Short Mill House, Quarry Office Park, Berea, East London PO Box 19367, Tecoma, 5214 Telephone: +27 (0)43 701 4800 Fax: +27 (0)43 721 0028 Bloemfontein 8–10 Reid Street, Westdene, Bloemfontein PO Box 12731, Brandhof, 9324 Telephone: +27 (0)51 403 6500 Fax: +27 (0)11 669 2952

Port Elizabeth 256 Cape Road, Newton Park, Port Elizabeth PO Box 27972, Greenacres, 6057 Telephone: +27 (0)41 392 8300 Fax: +27 (0)41 392 8543

Alexander Forbes Health is a licensed financial services provider (FSP 33471). CMS registration number ORG 3064.

Alexander Forbes Communications. Photos: Gallo Images 10294-Bonitas-DM-2015-10

37

ALEXANDER FORBES

Downloads

Option change form

Contribution rates for 2016

38