HealthPact
Select

HealthPact Select

Highlights

Unlimited hospital cover in a hospital of your choice Specialist procedures covered at 200% of the CMP tariff Out-of-hospital benefit of R4,800 per adult and R1,200 per child per year. Interest-bearing Medical Savings Account (MSA) Ample cover for all listed chronic conditions For diabetics, access to the Chronic Diabetic Endocrinology (CDE) Programme Generous maternity benefits Unlimited pathology at Pathcare/Lancet Laboratories (with GP referral)

Monthly contributions - 2012

Monthly contributions Amount Principal Member R3,115 (includes R259 contributed to MSA) Adult Beneficiary R3,115 (includes R259 contributed to MSA) Minor Beneficiary R507 (includes R42 contributed to MSA)

Medical Savings Account

The Medical Savings Account (MSA) is the uninsured portion of your benefit. It’s pre-funded in advance at the beginning of each benefit year, pooled per family for use by all beneficiaries, and included in monthly contributions. The funds in your MSA are used to cover day-to-day costs. Once your MSA is exhausted, these costs are covered from your day-to-day pool. MSA funds can also be used to pay for exclusions or tariff excesses. Once your MSA and day-to-day pool are depleted, day-to-day expenses are for your own account for the rest of the year. But any funds remaining in your MSA at the end of the benefit year accrue interest and are carried over to the next benefit year.

HealthPact Select in detail

Before you continue...

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. Take-home medication, outpatient services, and hospitalisation for the treatment of alcoholism, drug addiction and mental illnesses not classed under Prescribed Minimum Benefits (PMB) are payable from available MSA and then from available day-to-day pool.

Treatment in lieu of hospitalisation

CMP’s Select plan covers treatment and services provided by hospices and registered nurses in lieu of hospitalisation. Treatment is subject to CMP case management protocols and authorisation, limited to 15 days per beneficiary and covered at 100% of the CMP tariff. Costs are paid in full from available MSA, and thereafter from available day-to-day pool.

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. X-rays performed out of hospital are paid for from your available MSA, and thereafter from your day-to-day pool. 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 and medical specialists

Approved, hospital-related general and specialist procedures and operations are covered at 200% of the CMP tariff. You are also covered at 200% of the CMP tariff 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). Consultations are paid for from available MSA, and thereafter from the day-to-day pool.

Biokineticists and physiotherapists

All approved treatment in hospital is covered at 100% of the CMP tariff, subject to CMP case management protocols and authorisation. Consultations and treatment obtained out of hospital are covered at the same tariff, but are payable from available MSA and thereafter from available day-to-day pool.

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 R2,000 per family, thereafter payable from available MSA and then from available day-to-day pool. 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. Paediatric consultations are covered at the same rate, but are payable from available MSA and thereafter from available day-to-day pool. 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

General dental consultations and out-of-hospital orthodontic treatments are payable from available MSA and then from available day-to-day pool. In-hospital maxillo-facial procedures and oral surgeries are covered at 120% of the CMP tariff, subject to CMP case management protocols and authorisations. In-hospital dental implants, general dental treatments, orthodontic treatments, orthognathic procedures, periodontic and prosthodontic treatments are also paid for at 120% of the CMP tariff.

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 and Tier 2 curative treatment guidelines. Cover is subject to treatment plan approval at a CMP-nominated service provider. Anti-nausea medication and vitamins are paid for from available MSA and thereafter from available day-to-day pool. 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.

Spectacles, contact lenses  and supplementary services

All spectacles, contact lenses and supplementary services are covered in full, but are payable from available MSA and thereafter available day-to-day pool.

Prescribed medication

Chronic medication for all CMP’s listed chronic conditions is covered at 100% of cost up to a maximum of Single Exit Price, provided that the medication is obtained from our Preferred Provider or via the CDE Programme. Acute medication is paid for in full from available MSA and thereafter from available day-to-day pool.

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 Select 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 (PMBs may not be paid for from the MSA).

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. If funds are available, these benefit exclusions can be paid for from a member's Medical Savings Account, and thereafter from the day-to-day pool; once funds are depleted, these costs will be for the member’s own account.