HealthPact
Silver

HealthPact Silver

Highlights

Unlimited hospital cover in a hospital of your choice Specialist procedures covered at 100% of the CMP tariff Interest-bearing Medical Savings Account (MSA) for day-to-day expenses Up to two visits to the GP (not paid from savings) per beneficiary per year Separate cover for general dental practitioner consultations Acute medicine benefit for prescribed medication Unlimited pathology at Pathcare/Lancet Laboratories (with GP referral) Emergency ambulance cover

Monthly contributions - 2012

Monthly contributions Amount Principal Member R1,085 (includes R200 contributed to MSA) Adult Beneficiary R1,085 (includes R200 contributed to MSA) Minor Beneficiary R163 (includes R30 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 not covered under the insured benefit. They can also be used to pay for exclusions or tariff excesses. Once your MSA is 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 Silver 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 is payable from the acute medicine benefit (a total benefit of R320 per family), and thereafter from your MSA. Outpatient services and hospitalisation for the treatment of alcoholism, drug addiction and mental illnesses not classed as Prescribed Minimum Benefits (PMB) are payable from your MSA.

Treatment in lieu of hospitalisation

CMP’s Silver 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. Anything over 15 days may be paid for from your MSA.

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 MSA. 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 100% 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). Up to two GP visits per beneficiary per year are covered under insured benefits; all other consultations are paid for from your MSA. In-hospital biokinetics and physiotherapy is covered at 100% of the CMP tariff, subject to CMP case management protocols and authorisation.

Maternity and paediatrics

Expectant moms are covered for maternity confinements at 100% of the CMP tariff. Ante-natal consultations and foetal scans are covered up to a limit of R1,600 per family, thereafter payable from your MSA. 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 100% of the CMP tariff. You are also covered for out-of-hospital paediatric consultations at 100% of the CMP tariff, with an overall limit of R640 per child, thereafter payable from your MSA. 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 are covered at 100% of the CMP tariff, limited to R320 per beneficiary (thereafter payable from your MSA). Out-of-hospital orthodontic treatments are paid for from your MSA. In-hospital procedures are covered at 100% of the CMP tariff, subject to CMP case management protocols and authorisations. Dental implants, general dental treatment, orthodontic treatment, orthognathic procedures, periodontic treatment and prosthodontic treatment are paid for from your MSA.

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. Anti-nausea medication and vitamins are paid for from savings. 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 costs relating to spectacles, contact lenses and supplementary services are payable from your available savings.

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. Acute medication is paid for in full from the acute medicine benefit (a total benefit of R320 per family), and thereafter from savings.

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 Silver 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; once funds are depleted, these costs will be for the member’s own account.