HealthPact
Premium

HealthPact Premium

Highlights

Unlimited hospital cover in a hospital of your choice Specialist procedures covered at 200% of the CMP tariff Cover for selected out-of-hospital procedures Generous maternity benefits Unlimited pathology at Pathcare/Lancet Laboratories (with GP referral) Emergency ambulance cover

Monthly contributions - 2012

Monthly contributions Amount Principal Member R825 Adult Beneficiary R825 Minor Beneficiary R138

HealthPact Premium in detail

Before you continue...

It’s important to note that provision of the benefits specified below will always be subject to the rules of our Scheme. In addition, the following items will require pre-authorisation: All in-hospital cover, including maternity confinements Treatment in lieu of hospitalisation All procedures and operations, whether performed in or out of hospital Emergency ambulance services Oncology treatment

Hospitalisation

There is no overall limit for hospitalisation, which is covered at 100% of the CMP tariff. Your accommodation in general wards, High Care, Intensive Care and Specialised Intensive Care will be covered. You will also be covered for 100% of the cost of materials and medicines used during your stay. Being a hospital plan, HealthPact Premium does not provide cover for outpatient services, take-home medication, or hospitalisation or institutionalisation for the treatment of mental illness, alcoholism and drug addiction not classed as a Prescribed Minimum Benefit (PMB).

Treatment in lieu of hospitalisation

CMP’s Premium plan covers treatment and services provided by hospices and registered nurses in lieu of hospitalisation at 100% of the CMP tariff. Such treatment is subject to CMP case management protocols and authorisation, and limited to 15 days per beneficiary.

Emergency services

Services provided by a registered ambulance service are covered at 100% of the CMP tariff. Should you require a blood transfusion, CMP will cover 100% of the cost up to a maximum of 100% of the CMP tariff (in hospital).

Diagnostics – x-rays, radiology and pathology

Radiologist procedures (including angiograms, CT scans, MRI scans, Duplex Doppler scans, interventional radiology and nuclear medical investigation) are covered at 100% of the CMP tariff, up to a maximum of R6,000 per beneficiary. A co-payment of R1,500 per event will apply. Black and white x-rays performed as part of a hospital stay are covered at 100% of the CMP tariff. Out-of-hospital x-rays are not covered. Cover for pathology services provided by PathCare/Lancet Laboratories (in or out of hospital) is unlimited; pathology is covered at 100% of the CMP tariff, provided you obtain a GP referral.

GPs, specialists, biokineticists and physiotherapists

Approved, hospital-related general and specialist procedures and operations are covered at 200% of the CMP tariff.  You are also covered for laparoscopic and endoscopic procedures, as per the endoscopic surgeon’s guidelines, although co-payments do apply here (click here to see applicable co-payments). In-hospital biokinetics and physiotherapy are covered at 100% of the CMP tariff, subject to CMP case management protocols and authorisation. Treatment performed out of hospital will not be covered. Being a hospital plan, HealthPact Premium does not provide cover for out-of-hospital consultations.

Maternity and paediatrics

Expectant moms are covered for maternity confinements at 200% of the CMP tariff. Ante-natal consultations and foetal scans are covered up to a limit of R1,600 per family. To qualify for these benefits, you will need to be registered on our Mum’s the Word maternity programme. Once baby is registered as a beneficiary, all paediatric in-hospital procedures and operations are covered at 200% of the CMP tariff. You are also covered for out-of-hospital paediatric consultations at 200% of the CMP tariff, with an overall limit of R1,270 per child. New members who are already pregnant when they join CMP will not be covered for confinement or birth. Your baby, however, will still be covered once registered.

Dentistry, orthodontics and oral surgery

In-hospital maxillo-facial and orthodontic procedures are covered at 120% of the CMP tariff, subject to CMP case management protocols and authorisations. This plan does not cover related dental implants, general dental treatment, orthodontic treatment, orthognathic procedures, periodontic treatment and prosthodontic treatment. General dental practitioner and orthodontic consultations are also not covered on this plan.

Prostheses, implants and organ transplants

If introduced internally as an integral part of an operation, prostheses and implants are covered to a maximum of the applicable amount on CMP’s prosthetic price list. This benefit is limited to R35,000 per beneficiary per year, and is subject to CMP case management protocols and authorisations. Provided that treatment is provided by a CMP-nominated service provider, organ transplants are covered as a Prescribed Minimum Benefit at 100% of the CMP tariff.

Oncology and chronic renal dialysis

Cancer treatment is covered as a Prescribed Minimum Benefit, at 100% of the CMP tariff, and according to the SA Oncology Consortium’s (SAOC) Tier 1 treatment guidelines. Cover is subject to treatment plan approval at a CMP-nominated service provider. Members requiring chronic renal dialysis are covered for treatment at 100% of the CMP tariff, subject to CMP case management protocols and authorisations. Treatment is also covered as a Prescribed Minimum Benefit, and only at a CMP-nominated service provider. This plan does not provide cover for anti-nausea medication or vitamins.

Spectacles, contact lenses and supplementary services

Being a hospital plan, HealthPact Premium does not provide cover for spectacles, contact lenses and supplementary services. If you specifically require cover for these items, please consider one of our other two plans – HealthPact Silver or HealthPact Select.

Prescribed medication

Chronic medication for asthma, epilepsy and juvenile rheumatoid arthritis is covered at 100% of cost up to a maximum of Single Exit Price, provided that the medication is obtained from our Preferred Provider. Being a hospital plan, HealthPact Premium does not provide cover for acute medication.

Cover for PMBs

In addition to specified benefits, if any, all PMBs will be paid in accordance with current legislation if services are obtained from a Preferred Provider, or involuntarily obtained from any other service provider. This condition is subject to pre-authorisation, as well as to the rules of the full HealthPact Premium benefit set. Failure to adhere to these rules may result in payment only in accordance with the prescribed levels, as well as a co-payment.

Exclusions

As a mutual society that wants to support all its members, we wish we could pay for all claims without limitation. But doing this and still keeping our contribution levels affordable would be impossible. To avoid unnecessary expenditure and to protect the interests of all our members, we provide medical cover only for medically necessary treatments, procedures, products and services. Those considered medically unnecessary, or excessive, are excluded across all plans. Because HealthPact Premium does not include a day-to-day benefit or Medical Savings Account, all benefit exclusions are for the member’s own account.