Making the choice
YOUR HEALTH MATTERS
Bonitas updates for 2017 Your health, your
benefits
Focus on wellness
AIndustry few things to updates keep in mind
Health product changes 2017
HEALTH Alexander Forbes Health is a licensed financial services provider (FSP 33471). CMS registration number ORG 3064
ALEXANDER FORBES
Your options for 2017 Bonitas updates for 2017
Focus on wellness
Important definitions
4
Getting back on track
33
Are you considering changing your plan for 2017?
5
Antiretroviral drugs now available
35
A summary of the changes
7
A word on addiction
36
Why it’s important to review your plan every year
9
Embrace the benefits of living healthy
38
Choosing a medical aid plan that meets your needs
10
Chronic cover
11
Deductibles
13
Understanding the supplementary benefits
14
What contributes to medical aid increases?
20
The role of health insurance in meeting your medical needs
41
Hospital networks
21
Your rights and responsibilities
43
GP and specialist networks
28
Prescribed minimum benefits explained
44
Pharmacy Direct
29
Details on Sanlam Reality
30
Industry updates
Downloads
Option change form
46
Contribution rates for 2017
46
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.
2
YOUR OPTIONS FOR 2017
BONITAS UPDATES FOR 2017
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.
HEALTH PRODUCT CHANGES 2017
Are you considering changing your plan for 2017?
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 2017, but please do take note of any changes for 2017 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 2017.
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 45 of the magazine.
5
ALEXANDER FORBES
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 2017. 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.
6
Bonitas website www.bonitas.co.za
Alexander Forbes Health Bonitas website Website: www.afhealth.co.za/bonitas
HEALTH PRODUCT CHANGES 2017
A summary of the changes
Bonitas Medical Fund launched its 2017 product offering on 29 September 2016. Below is an overview of the most important changes, effective from 1 January 2017. We will present a detailed analysis at year-end planning meetings.
The contribution increase across all plans for 2017 is 11.9%.
New benefit option for 2017 BonComplete The BonComplete is a new generation option and offers the following benefits: ■ Unlimited hospitalisation at 100% of the Bonitas Rate ■ Cover for 31 chronic conditions (including ADD cover for dependants under 18) ■ Savings, self-payment gap and above threshold benefit ■ Basic and specialised dentistry paid from risk ■ Cover for internal and external prostheses ■ Wellness extender benefits ■ Maternity benefit paid from risk ■ Childhood illness and infant paediatric benefits ■ General and specialised radiology in and out of hospital with no copayments
Benefit changes Traditional options
Hearing aid benefit The hearing aid benefit has been restructured as follows: ■A 24-month claiming period is now required on the BonComprehensive, BonClassic, Standard and Standard Select options. ■T he copayments on the Standard and Standard Select options have increased from 10% to 20%. ■T he hearing aid benefit has been removed on the Primary option. Realignment of specialised radiology ■T he benefit limit will be applicable to tests done in and out of hospital on the Standard, Standard Select and BonSave options. Optical benefits ■T he optical benefit on the BonClassic, Standard, Standard Select and Primary options will now only be accessible once in a 24-month period. ■T his will be based on the date of the previous optical claim.
■ The Standard and Standard Select options will be changed back to traditional options. ■ The Savings portion has been removed and any accrued savings balances will be paid out or transferred to members where applicable.
Preventative care benefit for mammograms
Over the counter medicine
Specialist referral
■ An over the counter medicine sub-limit within the day-to-day benefit has been reintroduced on the Standard and Standard Select options.
■C laims for specialist consultations without a valid referral from a GP will not be paid from risk. ■T his is to assist in enhancing the coordination of care.
■T he age band for mammograms has been reduced from 50 to 40 on the BonComprehensive, BonClassic, Standard and Standard Select options.
7
ALEXANDER FORBES
Foot orthotics ■T he foot orthotics benefit which was previously paid from risk will now be paid from the savings on BonComprehensive, BonClassic, BonComplete, BonSave and BonFit options. Physiotherapy for mental health admissions ■C over for physiotherapy in hospital will be excluded for mental health admissions on all options. Pneumococcal vaccines ■O ne pneumococcal vaccine every five years for members aged 65 years. This benefit is now covered on all options, including BonEssential and BonCap. BonCap income bands ■ The income bands have increased by 7%. Increase on copayments for elective hospital procedures ■T he copayments* for elective hospital procedures on the BonSave, Primary, BonFit and BonEssential options have increased as follows: 2016
2017
% increase
R1 050
R1 300
23.8%
R2 650
R3 300
24.5%
R5 250
R6 500
23.8%
*The increase will not affect members admitted for emergencies and Prescribed Minimum Benefits (PMB) related conditions. Hospital admission copayment Members have access to all private hospitals countrywide, but a 30% copayment for each admission will apply at the following hospitals: ■ Rosepark Hospital ■ Bedford Gardens Private Hospital ■ Brenthurst Clinic ■ Carstenhof Clinic ■ Flora Clinic ■ Genesis Clinic (Saxonwold) ■ Wilgeheuwel Private Hospital ■ Eugene Marais Hospital ■ Faerie Glen Hospital ■ Little Company of Mary Hospital (Groenkloof) ■ Wilgers Hospital ■ Hilton Life Private Hospital ■ Kingsbury Hospital ■ Vincent Pallotti Hospital Please note: This does not apply to the Standard Select, BonFit and BonCap options, as they make use of specific hospital networks.
8
Babyline ■A ccess to a telephone helpline for medical advice, 365 days a year (24/7). ■F or members with children under two and a half years old. ■O ffered through PAED-IQ. Bonitas Connect ■M obile app that allows members to get an electronic membership card, chat online regarding queries, send documents and download documents. ■A vailable on Apple, Google, Microsoft and Blackberry Stores. Sanlam Reality ■A lifestyle, wellness, rewards and financial education programme available to all Bonitas members. ■O ffers wealth, health, travel, entertainment, personal services and day-to-day savings benefits. Alexander Forbes Health is available to help you and your employees make good choices in 2017 because your health matters. Yours in health Alexander Forbes Health Follow us on Twitter #AF_Health
HEALTH PRODUCT CHANGES 2017
Why it’s important
to reassess your plan selection every year
The end of the year is a time when many people look forward to a well-deserved break, summer, sun and special family time. It’s also the time of the year when the medical schemes announce their benefit changes and contribution increases. Most people are under the impression that reviewing their medical scheme option is time-consuming and too complicated, so they simply choose to stay on their current option. A conversation with your Alexander Forbes healthcare consultant can help make sure that you’re knowledgeable about your coverage and comfortable that your option will meet your needs in the coming year.
Keep lifestyle changes in mind If you have a new addition to the family or are planning to have a baby in the future, it is a good idea to review your healthcare option. Small children are exposed to all kinds of illnesses and families with very young children fall into one of the highest claims categories. Premature labour is a trend that is unfortunately on the rise. Premature birth ranks among the top ten highest costs and has had the most frequent admissions in the industry for the last few years.
Changes to your health status could mean that your existing option is no longer suitable for your needs. Risk tends to increase with age, so your medical aid should be adjusted as you move on through life’s many stages. Chronic needs might change because although all medical scheme options make provision for 27 chronic conditions, not all options provide the same medication cover. The comprehensive options usually cover more chronic conditions and offer more comprehensive benefits. Planning a procedure or operation? Do you know if there are sub-limits, copayments or deductibles on your option? Do you know at what rate your option will reimburse your providers? Then again, you may even be overinsured and could save money by reducing your level of cover. Or, you may have both healthy and sick members in your family. By analysing your current option, your healthcare consultant can advise you on possible solutions. As an example, a solution might be to split the family scheme membership. Most schemes have options with GP and hospital networks and regularly review these networks, adding to and removing from their network listings. If you are not aware of this, it could mean that you have to pay a penalty. Get to know your hospital network and what level of access you have to hospitals in your area.
Your consultant will complete a needs analysis of your requirements to establish exactly what type of cover you and your family need. So, before you go on that well-deserved holiday, make a note to check in with your healthcare consultant because your health matters.
9
ALEXANDER FORBES
Choosing a plan that meets your needs
It is important that you reassess your current medical aid cover at least once a year to make sure that what you’ve chosen will continue to meet your family’s needs.
By reviewing your own and your dependants’ use of healthcare services over the past two to three years and considering what healthcare needs you may have in the near future, you can make a more informed decision. Bonitas can provide you with a claims summary, listing all the claims that you’ve made over a specific period of time. This will allow you to see what you have spent both in and out of hospital. Look at the benefits available in 2017 on your chosen plan and compare it with the benefits on the same plan in 2016. If you have experienced any shortfalls in 2016, it may mean that you need to look at an alternative plan, reducing the likelihood of any shortfalls in 2017.
■■ Will in-hospital reimbursement rates and sub-limits apply?
Remember that when changing your plan you need to ensure that you’ve considered possible changes in the plan you are thinking of moving to:
■■ Will your chronic condition and medication continue to be covered? ■■ Will copayments be applicable for in- and out-of-hospital treatment? ■■ Will there be enough money available for the year to cover your day-to-day expenses?
NOTE: If you wish to change your plan, remember you need to communicate your change with your employer, or directly with Bonitas Medical Fund if your cover is not through an employer.
10
HEALTH PRODUCT CHANGES 2017
Chronic cover Bonitas covers life-threatening conditions that require ongoing medication and the following is applicable to the benefit:
A list of chronic medication covered under each option Prescribed minimum benefits (PMBs) are included Free delivery of chronic medication through Pharmacy Direct
BonComprehensive
Standard
BonClassic
Standard Select
BonComplete
BonSave
■■ 62 chronic conditions covered ■■ Comprehensive and restrictive formulary ■■ 27 standard chronic conditions covered on the Chronic Disease List and 35 conditions covered on the Additional Disease List ■■ 48 chronic conditions covered ■■ Restrictive formulary ■■ 27 standard chronic conditions covered on the Chronic Disease List and 21 conditions covered on the Additional Disease List ■■ 31 chronic conditions covered ■■ Restrictive formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable ■■ 27 standard chronic conditions covered on the Chronic Disease List and four conditions covered on the Additional Disease List
■■ 44 chronic conditions covered ■■ Comprehensive and restrictive formulary ■■ 27 standard chronic conditions covered on the Chronic Disease List and 17 conditions covered on the Additional Disease List ■■ 44 chronic conditions covered ■■ Comprehensive and restrictive formulary ■■ 27 standard chronic conditions covered on the Chronic Disease List and 17 conditions covered on the Additional Disease List ■■ 27 chronic conditions covered on the Chronic Disease List ■■ Restrictive formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable
11
ALEXANDER FORBES
BonFit
■■ 27 chronic conditions covered on the Chronic Disease List ■■ Restrictive formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable
Primary
■■ 27 chronic conditions on the Chronic Disease List ■■ Restrictive formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable
BonEssential
BonCap
■■ 27 chronic conditions covered on the Chronic Disease List ■■ BonCap medicine formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable
Student Plan
■■ 27 chronic conditions covered on the Chronic Disease List ■■ BonCap medicine formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable
■■ 27 chronic conditions covered on the Chronic Disease List ■■ Restrictive formulary and subject to use of Designated Service Providers, otherwise a 40% copayment will be applicable
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.
We’re making things simple with EasyPay Bonitas have partnered with EasyPay to make it easier for members to pay amounts owed to Bonitas (this excludes monthly contributions). This includes historical debt and members’ portions. The EasyPay service is available through most retail outlets including Checkers, PEP and Spar.
A unique EasyPay number will be sent to all Bonitas members so that they can use this number at an EasyPay outlet when paying a debt.
PLEASE NOTE 12
This service should not be used for the payment of monthly medical aid contributions, as the Scheme will continue to collect these contributions from employer groups by debit order, EFT or cash.
HEALTH PRODUCT CHANGES 2017
Deductibles Did you know?
The BonSave, BonFit, Primary and BonEssential plans have deductibles for certain in-hospital procedurest. A deductible is an amount that you must pay up front, when you’re admitted into a hospital or day clinic for a particular procedure, which you cannot claim back from the medical scheme.
The following procedures attract a deductible: When you have to pay Planned hospital procedure ■■ 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 ■■ Arthroscopy ■■ Diagnostic laparoscopy ■■ Laparoscopic appendectomy ■■ Laparoscopic hysterectomy ■■ Percutaneous radiofrequency ablations ■■ Percutaneous rhizotomies ■■ Back surgery including spinal surgery ■■ Joint replacement (except prescribed minimum benefits) ■■ Laparoscopic pyeloplasty ■■ Laparoscopic radial prostatectomy ■■ Nissen fundoplication (reflux surgery)
Amount due up front
R1 300
R3 300
R6 500
13
ALEXANDER FORBES
Understanding
the supplementary benefits
The supplementary benefits are paid from risk and as such will not affect your day-to-day benefits. They can be used for treatments in and out of hospital. The benefits must be authorised and they are 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 ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ One amniocentesis ■■ Private ward after delivery ■■ A Bonitas baby bag (you must register for this after getting preauthorisation for the delivery)
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary each year
Babyline
PSA test (between the ages of 55 and 69) for those considered to be at high risk for prostate cancer
One full lipogram (20+ years of age) per five-year cycle
■■ For children under two and a half years old ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
14
■■ One thyroid stimulating hormone test for infants who are less than one month old ■■ Childhood immunisation according to the expanded programme on immunisation in South Africa
■■ One mammogram between the ages of 40 and 74 for each two-year cycle ■■ One pap smear every three years for women aged 21 and 65
Infant paediatric benefit
■■ Three consultations with paediatrician for children under one year ■■ Two consultation with a paediatrician for children between the ages of one and two years ■■ Two GP consultations for children between the ages of two and twelve
HEALTH PRODUCT CHANGES 2017
Wellness benefit
One assessment per beneficiary each year at a participating pharmacy, biokineticist or a Bonitas wellness day limited to the following: ■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist to hip ratio assessment
Wellness extender benefit
Limited to R2 100 per family each year, subject to the registration and completion of health risk assessment per beneficiary. They may choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapy consultation ■■ Wearable devices (subject to approval) ■■ A programme to stop smoking All claims are paid at the Bonitas Rate
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years ■■ One bone density screening every five years for female members aged 65 and above
BonComplete Maternity care (per event)
Infant paediatric benefit
Childhood illness benefit
General health
Cardiac health
Women’s health
Elderly health
Wellness Benefit
Wellness extender benefit
■■ 6 antenatal consultations ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ One amniocentesis ■■ A Bonitas baby bag (you must register for this after getting preauthorisation for the delivery)
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members between the ages of 50 and 75 years
■■ Two consultations per beneficiary under the age of one year ■■ One consultation per beneficiary between one and two years old
One full lipogram (20+ years of age) per five-year cycle
■■ One GP consultation per beneficiary between the ages of two and twelve
■■ One mammogram between the ages of 50 and 74 for each two-year cycle ■■ One pap smear between the ages of 21 and 65) for each three-year cycle
■■ Limited to R1 450 per family each One assessment per beneficiary each year at a participating year, subject to the registration and pharmacy, biokineticist or a Bonitas completion of health risk assessment wellness day limited to the following: per beneficiary. They may choose from the following: ■■ Blood pressure test ■■ GP consultation ■■ Glucose test ■■ Biokineticist consultation ■■ Cholesterol test ■■ Dietician consultation ■■ Body mass index ■■ Physiotherapy consultation ■■ Waist to hip ratio assessment ■■ A programme to stop smoking All claims are paid at the Bonitas Rate
Babyline
■■ For children under two and a half years ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
15
ALEXANDER FORBES
BonClassic
Maternity care (per event)
Women’s health
General health
Cardiac health
■■ 12 antenatal consultations ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ 1 amniocentesis ■■ A Bonitas baby bag (you must register for this after getting pre-authorisation for the delivery)
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary each year
■■ One mammogram for women between the ages of 40 and 74 over each two-year cycle ■■ One pap smear for women between the ages of 21 and 65 over each three-year cycle
One full lipogram for members 20+ years of age per fiveyear cycle
Wellness benefit
Wellness extender benefit
One assessment per beneficiary each year at a participating pharmacy, biokineticist or a Bonitas wellness day and is limited to the following: ■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist to hip ratio assessment
Limited to R1 450 per family per year, subject to the registration and completion of health risk assessment per beneficiary. They may choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapy consultation ■■ A programme to stop smoking All claims are paid at the Bonitas Rate
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years ■■ One bone density screening every five years for female members aged 65 and above
Babyline
■■ For children under two and a half years of age ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
Standard & Standard Select
Maternity care (per event)
■■ 12 antenatal consultations ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ One amniocentesis ■■ A Bonitas baby bag (you must register for this after getting pre-authorisation)
General health
Infant paediatric benefit
■■ Two consultations per beneficiary under the age of one ■■ Two consultations per beneficiary between the ages one and two years
Cardiac health
■■ One annual HIV test per beneficiary One full lipogram (20+ years of age) per five-year each year ■■ One annual flu vaccine per beneficiary cycle per year
Standard & Standard Select
16
Childhood illness benefit Two GP consultations per beneficiary aged between two and twelve years
Women’s health ■■ One mammogram for women between the ages of 50 and 74 per two-year cycle ■■ One pap smear for women between the ages of 21 and 65 for each three-year cycle
HEALTH PRODUCT CHANGES 2017
Wellness benefit
One 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
Wellness extender benefit
Limited to R1 450 per family each year, subject to the registration and completion of health risk assessment per beneficiary. They may choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapy consultation ■■ A programme to stop smoking All claims are paid at the Bonitas rate
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years
Babyline
■■ For children under two and a half years’ old ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
BonSave & BonFit
Maternity care (per event)
■■ Six antenatal consultations ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ R1 100 for antenatal classes ■■ One amniocentesis ■■ A Bonitas baby bag (you must register for this after getting preauthorisation)
Infant paediatric benefit
■■ Two consultations per beneficiary under the age of one year ■■ One consultation per beneficiary aged between one and two years old
General health
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary each year
Wellness benefit One assessment per beneficiary each year at a participating pharmacy, biokineticist or a Bonitas wellness day limited to the following: ■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist to hip ratio assessment
Childhood illness benefit
One GP consultation per beneficiary aged between two and twelve years
Childhood illness benefit
One GP consultation per beneficiary between ages two and twelve
Wellness extender benefit
Limited to R1 050 per family per year, subject to the registration and completion of health risk assessment per beneficiary. They may choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapy consultation ■■ A programme to stop smoking All claims are paid at the Bonitas Rate
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years
Babyline
■■ For children under two and a half years old ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
17
ALEXANDER FORBES
Primary
Maternity care (per event)
■■ Six antenatal consultations ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ R1 050 for antenatal classes ■■ One amniocentesis ■■ A Bonitas baby bag (you must register for this after getting preauthorisation)
Infant paediatric benefit
■■ One consultation per beneficiary under the age of one year ■■ One consultation per beneficiary between the ages of one and two years
General health
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary each year
Wellness benefit
One assessment per beneficiary each year at a participating pharmacy, biokineticist or a Bonitas wellness day limited to the following: ■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist to hip ratio assessment
Childhood illness benefit
■■ One GP consultation per beneficiary between the ages of two and twelve years
Women’s health One pap smear for women aged between 21 and 65) per three-year cycle
Wellness extender benefit
Limited to R1 050 per family per year, subject to the registration and completion of health risk assessment per beneficiary. They may choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapy consultation ■■ A programme to stop smoking All claims are paid at the Bonitas Rate
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years
Babyline
■■ For children under two and a half years ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
BonEssential
Maternity care (per event)
■■ Six antenatal consultations ■■ Two 2D scans ■■ Four postnatal consultations with a midwife ■■ One amniocentesis ■■ A Bonitas baby bag (you must register for this after getting pre-authorisation)
General health
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary each year
Wellness benefit
■■ One assessment per beneficiary each year at a participating pharmacy, biokineticist or a Bonitas wellness day limited to the following: ■■ Blood pressure test ■■ Glucose test ■■ Cholesterol test ■■ Body mass index ■■ Waist to hip ratio assessment
Childhood illness benefit One GP consultation per beneficiary between two and twelve years
Wellness extender benefit Limited to R750 per family each year, subject to the registration and completion of health risk assessment per beneficiary. They may choose from the following: ■■ GP consultation ■■ Biokineticist consultation ■■ Dietician consultation ■■ Physiotherapy consultation ■■ A programme to stop smoking All claims are paid at the Bonitas Rate
18
HEALTH PRODUCT CHANGES 2017
BonEssential
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years
Babyline
■■ For children under two and a half years ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
BonCap
Babyline
■■ For children under two and a half years ■■ Access to telephone helpline for 24/7 medical advice, including weekends and holidays
Elderly health
■■ One pneumococcal vaccine every five years for members aged 65 and over ■■ One stool test for colon cancer for members aged between 50 and 75 years
General Health
■■ One annual HIV test per beneficiary each year ■■ One annual flu vaccine per beneficiary each year
19
ALEXANDER FORBES
What contributes to medical aid increases?
Alexander Forbes Health expects to see medical scheme increases continuing to exceed current consumer price inflation (CPI) rates in 2017. 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 then 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 9.4%. The Council for Medical Schemes recently released its 2015/2016 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 23.5%. ■■ Acute and chronic medication costs increased by 7.1%. ■■ Supplementary and allied health professional costs increased 12.7%. ■■ Total medical scheme non-healthcare expenditure rose by 7.5%. ■■ Expenditure on general practitioners increased by 7.6%.
■■ The increase in hospital and service provider tariffs up to 2%. The following factors have been identified as having contributed to medical inflation:
■■ Building reserves to the required statutory solvency level up to 3% ■■ Demand side utilisation impact ranges from 2% to 4.5% ■■ Supply side utilisation impact ranges from 1.5 to 4%
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 are
20
contributing to utilisation increases as well as the cost of medicines to treat serious illnesses. Within this context, it is important to understand that medical scheme increases are based on sound financial governance and not on profit motives.
HEALTH PRODUCT CHANGES 2017
BonCap
and standard select hospital networks BONCAP HOSPITAL NETWORK *Disclaimer: Subject to approval by Council for Medical Schemes. This list is subject to change, therefore please refer to the website.
Type
Clinics – Day Surgery
Province
Hospital
Eastern Cape
Medical Forum Theatre
Free State
Welkom Medical Centre
Free State
Cure Day Clinics – Bloemfontein
Free State
Bethlehem Medical Centre
Free State
Bonnet Dr M L and Partners trading as Citymed Dagkliniek
Gauteng
The Berg Day Theatre
Gauteng
Cure Day Clinics – Midstream
Gauteng
Cure Day Clinics – Erasmuskloof
Gauteng
Intercare Day Hospital Hazeldean
Gauteng
Intercare Day Hospital Irene
Gauteng
Intercare Sandton Day Hospital
Gauteng
Medgate Day Clinic
Gauteng
Fordsburg Clinic
Gauteng
Cure Day Clinics – Medkin
Gauteng
Life Pretoria North Surgical Centre
Gauteng
Mayo Clinic of South Africa
Gauteng
Life Brooklyn Surgical Centre
Gauteng
Fauchard Clinic
Gauteng
Birchmed Surgical Centre
Gauteng
Netcare Constantia Day Hospital
Gauteng
Karibu Day Clinic
Gauteng
Medicross Constantia Park – Day Surgery
Gauteng
Boksburg Medical & Dental Centre (Theatre)
Gauteng
Germiston Medical & Dental Centre
Gauteng
Medicross Silverton Medical & Dental Centre (Theatre)
Gauteng
Mercidoc Day Clinic
KwaZulu-Natal
Care Clinic (Westville)
KwaZulu-Natal
Shelly Beach Day Clinic
KwaZulu-Natal
Westridge Surgical
KwaZulu-Natal
KZN Day Clinic
KwaZulu-Natal
Bluff Medical & Dental Centre
KwaZulu-Natal
Medicross Malvern – Day Surgery
Limpopo
Mediclinic Limpopo Day Clinic
Mpumalanga
Kriel Medical Centre
Mpumalanga
Emalahleni Day Hospital 21
ALEXANDER FORBES
BONCAP HOSPITAL NETWORK *Disclaimer: Subject to approval by Council for Medical Schemes. This list is subject to change, therefore please refer to the website.
Type
Clinics – Day Surgery
Private Clinic
Private Hospital
Private Hospital (B-status)
22
Province
Hospital
North West
Medicross Potchefstroom Baby Clinic
Western Cape
Life Sport Science Orthopaedic Surgical Day Centre
Western Cape
Cure Day Clinic – Stephen's Paarl
Western Cape
George Surgical Centre
Western Cape
The Surgical Institute
Western Cape
Monte Vista Kliniek
Western Cape
Cure Day Clinics – Somerset West
Western Cape
Mediclinic Durbanville – Day Clinic
Western Cape
Advanced Durbanville Surgical Centre
Western Cape
Drs Aevitas Ingelyf tradin as Aevitas Clinic
Western Cape
Medicross Langeberg Medical & Dental Centre
Western Cape
Medicross Parow Medical & Dental Centre (Theatre)
Western Cape
Medicross Tokai Family Medical & Dental Centre
Gauteng
Centre of Advanced Medicine trading as Medical Centre
KwaZulu-Natal
Medicross Pinetown Medical & Dental Centre (Theatre)
Western Cape
Intercare Day Hospital – Century City
Western Cape
Cango Medicentre
Eastern Cape
Life Isivivana Private Hospital
Eastern Cape
Life Beacon Bay Hospital
Eastern Cape
Life St Mary's Private Hospital
Eastern Cape
Life St James Hospital
Eastern Cape
Life Queenstown Private Hospital
Eastern Cape
Life St George's Hospital
Eastern Cape
Life St Dominic's Hospital
Eastern Cape
Life Mercantile Private Hospital
Free State
Netcare Vaalpark Hospital
Free State
Life Rosepark Hospital
Gauteng
Life Fourways Hospital
Gauteng
Genesis Clinic – Saxonwold
Gauteng
Netcare Clinton Hospital
Gauteng
Life Brenthurst Clinic
Gauteng
Netcare Jakaranda Hospital
Gauteng
Netcare Femina Hospital
Gauteng
Life Robinson Private Hospital
Gauteng
Netcare Union Hospital
Gauteng
Life Flora Clinic
Gauteng
Netcare Unitas Hospital
Gauteng
Life Carstenhof Clinic
Gauteng
Netcare Sunward Park Hospital
Gauteng
Netcare Moot General Hospital
Gauteng
Bedford Gardens Private Hospital
HEALTH PRODUCT CHANGES 2017
BONCAP HOSPITAL NETWORK *Disclaimer: Subject to approval by Council for Medical Schemes. This list is subject to change, therefore please refer to the website.
Type
Private Hospital
Province
Hospital
Gauteng
Netcare Linmed Hospital
Gauteng
Life Wilgeheuwel Hospital
Gauteng
Netcare Bougainville Private Hospital
Gauteng
Life Suikerbosrand Clinic
Gauteng
Netcare Montana Private Hospital
KwaZulu-Natal
Netcare Kokstad Private Hospital
KwaZulu-Natal
Netcare Parklands Hospital
KwaZulu-Natal
Netcare St Augustine's Hospital
KwaZulu-Natal
Netcare St Anne's Hospital
KwaZulu-Natal
Netcare Kingsway Hospital
KwaZulu-Natal
Netcare the Bay Hospital
Limpopo
Netcare Pholoso Hospital
Mpumalanga
Life Piet Retief Hospital
Mpumalanga
Life Cosmos Hospital
Mpumalanga
Life Midmed Hospital
North West
Life Anncron Hospital
North West
Life Peglerae Hospital
Western Cape
Netcare Kuils River Hospital
Western Cape
Netcare Blaauwberg Hospital
Western Cape
Netcare Ceres Private Hospital
Western Cape
Netcare Christiaan Barnard Memorial Hospital
Western Cape
Life Kingsbury Hospital
Western Cape
Netcare N1 City Hospital
Western Cape
Life Bay View Private Hospital
Western Cape
Life Knysna Private Hospital
Western Cape
Life West Coast Private Hospital
Western Cape
Mediclinic Wesfleur
23
ALEXANDER FORBES
SELECT HOSPITAL NETWORK *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
Private clinic
Gauteng KwaZulu-Natal Western Cape
24
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) 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 of South Africa Medgate Day Clinic Medicross Constantia Park – Day Surgery Medicross Silverton Medical & Dental Centre (Theatre) Mercidoc Day Clinic Netcare Constantia Day Hospital The Berg Day Theatre Bluff Medical & Dental Centre Care Clinic (Westville) KZN Day Clinic Medicross Malvern – Day Surgery Shelly Beach Day Clinic Westridge Surgical Mediclinic Limpopo Day Clinic Emalahleni Day Hospital Kriel Medical Centre Medicross Potchefstroom Baby Clinic Advanced Durbanville Surgical Centre Cure Day Clinic – Stephen's Paarl Cure Day Clinics – Somerset West Drs Aevitas Ingelyf trading as Aevitas Clinic George Surgical Centre Life Sport Science Orthopaedic Surgical Daycentre Mediclinic Durbanville – Day Clinic Medicross Langeberg Medical & Dental Centre Medicross Parow Medical & Dental Centre (Theatre) Medicross Tokai Family Medical & Dental Centre Monte Vista Kliniek The Surgical Institute Centre of Advanced Medicine Medicross Pinetown Medical & Dental Centre (Theatre) Cango Medicentre Intercare Day Hospital – Century City
HEALTH PRODUCT CHANGES 2017
SELECT HOSPITAL NETWORK *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
Eastern Cape
Life Queenstown Private Hospital Life St Dominic's Hospital Life St George's Hospital Life St James Hospital
Free State
Life St Mary's Private Hospital Life Rosepark Hospital Netcare Vaalpark 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
Gauteng
Netcare Bougainville Private Hospital Netcare Clinton Hospital Netcare Femina Hospital Netcare Jakaranda Hospital Netcare Linmed Hospital Netcare Montana Private Hospital Netcare Moot General Hospital
Private hospital
Netcare Sunward Park Hospital Netcare Union Hospital Netcare Unitas Hospital 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 Hospital Life Cosmos Hospital
Mpumalanga
Life Midmed Hospital Life Piet Retief Hospital
North West
Life Anncron Hospital Life Peglerae Hospital Life Bay View Private Hospital Life Kingsbury Hospital Life Knysna Private Hospital Life West Coast Private Hospital
Western Cape
Mediclinic Wesfleur Netcare Blaauwberg Hospital Netcare Ceres Private Hospital Netcare Christiaan Barnard Memorial Hospital Netcare Kuils River Hospital Netcare N1 City Hospital
25
ALEXANDER FORBES
GP
and specialist networks
Bonitas Medical Fund is always looking for new ways to help you save money while still 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 give you more control over your health and medical expenses. Why was it introduced? ■■ Bonitas noticed that thousands of members were visiting many different GPs for different reasons. ■■ This resulted in duplicate testing and costs, unnecessary doctor visits and an increase in out-ofpocket 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 members with the guarantee that they will not be charged more than the Bonitas tariff. ■■ To check if your GP is on the Bonitas network, visit www.bonitas.co.za or call 0860 002 108.
The specialist network ■■ Launched in 2012, this network gives you access to over 2 000 specialists nationally. ■■ Gives you access to specialist services at a negotiated rate for both in- and out-of-hospital costs. ■■ Claims will be paid in full and you don’t have to pay any shortfalls. ■■ If you have a prescribed minimum benefit (PMB) condition and have reached the limits on your dayto-day benefit, you can continue to consult with the specialist within the network without incurring any copayments. ■■ To check if your specialist is on the Bonitas network, visit www.bonitas.co.za or call 0860 002 108.
To check if your GP or specialist is on the Bonitas network, visit the Bonitas website or call 0860 002 108. 26
HEALTH PRODUCT CHANGES 2017
Pharmacy Direct Has your chronic condition and medication been approved by the Chronic Medicine Management (CMM) at Bonitas?
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
IF NO
Fax the application form and a copy of the script to Pharmacy Direct on 086 611 4000 or 1 or 2 or 3. 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 us a lifestyle, wellness, rewards and financial education programme available to all Bonitas members.
Reality Health
Reality Core
Reality Club
Single & Family
Single & Family
Single
Wealth Sanlam Premier risk products
√
–
–
Sanlam savings products
√
√
–
Sanlam Gap Cover
√
√
√
Wealth Sense
√
√
√
Money Saver card
√
√
√
Discount coupons
–
–
√
Discounted magazines
–
–
√
Virgin Active Gym
√
–
–
Planet Fitness Gym
√
√
√
JustGym
√
√
√
Mango flights
√
√
–
Emirates flights
√
–
–
Protea Hotels Marriott
√
√
–
Tempest car hire
√
√
–
Uber airport transfers
√
√
–
Bidvest Premier Lounge
√
–
–
Intercape bus
–
–
√
Day-to-day savings
Health
Travel
28
HEALTH PRODUCT CHANGES 2017
Reality Health
Reality Core
Reality Club
Single & Family
Single & Family
Single
Entertainment Nu Metro movies and refreshments
√
√
√
Computicket show and sport
√
–
√
Dining
√
–
–
Simfy Africa music streaming
√
√
–
Wi-Fi
√
–
–
Reality magazine
√
√
–
Quarterly printed newsletter
–
–
√
Personal Assistant
√
√
–
Dial-A-Teacher
–
–
√
Legal Assistance
–
–
√
Trauma and Medical Assist
–
–
√
Personal services
Membership fees Single member
Family
Reality Club
R35
Reality Core
R75
R105
R170
R215
Reality Health
im nefits a e b e h T e you sav to help el on trav nt, y e n o m e tertainm n e d n a e your improv d give you an health al financi le b a lu a v tips. fitness
No family membership
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.
29
ALEXANDER FORBES
30
FOCUS ON WELLNESS 31
ALEXANDER FORBES
Getting back on track in 2017
5 1
– Dr Lerato Motshudi, AF Health
simple healthy lifestyle tips
HEALTHY EATING
A balanced diet is one with a variety of nutrients.
Fibre is important for regular bowel functioning and for absorption of nutrients by the body.
Get protein from meat, fish, poultry, eggs and cheese.
Get fibre from fruit skins, bran and seeds.
Carbohydrates are sugars that alleviate constipation and help prevent colon cancer.
Fats are important for insulation, protection of some organs in the body, and healthy hair and skin. There are good and bad fats. Avoid trans fats – you can usually find this written on food packaging as ‘hydrogenated’ oils. Instead, choose foods with monounsaturated or polyunsaturated fats.
Get good fats from fish, nuts, olives, avocado and seeds.
32
Minerals are found in a variety of foods and strengthen different parts of the body. Look our for these minerals: iron, sodium, magnesium, calcium and selenium. Vitamins control chemical reactions in our bodies. Most vitamins are not produced by the body and must therefore be eaten in our diet.
Get carbohydrates from fruit, nuts, rice and pasta.
Protein is good for building muscle and other tissues in the body.
Consider a multivitamin supplement if you don’t have a nutritious diet.
Water makes up about 60% of our body weight. It’s important for hydration, temperature control and transport of waste products and other material in the body.
It’s recommended that we drink eight glasses of water a day.
HEALTH PRODUCT CHANGES 2017
2
PHYSICAL ACTIVITY
A healthy amount of physical activity means you’re moving your body and using up energy. Exercising, gardening and playing with the kids are all forms of physical activity. Work on spending at least 150 minutes on moderate physical activity, or 75 minutes on vigorous activity every week.
4
STOP SMOKING
3
5
Smoking is hazardous not only to your lungs but also to your heart. It increases the chances of emphysema, respiratory diseases, lung cancer and heart disease. Secondary smoking is just as dangerous.
CUT DOWN ON ALCOHOL
Red wine contains antioxidants that protect the heart. Drinking a glass a day could offer benefits against heart disease. But excessive drinking has detrimental effects on the brain, liver and pancreas over time. GO FOR YOUR YEARLY MEDICAL CHECK-UP
Each year find out your status on blood pressure, blood glucose, cholesterol, body mass index (BMI) and HIV. Women should take this time to get a proper examination of their breasts and a pap smear, while men should investigate abnormalities of the prostate.
33
ALEXANDER FORBES
Antiretroviral drugs now available
Antiretroviral drugs now available for anyone who tests HIV positive, regardless of CD4 count The South African Ministry of Health has committed to follow the latest World Health Organization (WHO) guidelines on prescribing antiretroviral (ARV) drugs to people infected with HIV.
Why is this good news? ■■ Every person infected with HIV will now be granted access to ARV treatment. ■■ They will no longer have to wait for their CD4 cell count to drop below 500 cells/mm3 before they can start taking ARVs. ■■ There’s no need to wait for tuberculosis (TB) infection or any other signs of HIV before beginning ARV treatment. ■■ High-risk individuals can take pre-exposure prophylaxis (PreP) daily as an additional preventative measure from infection. This means that high-risk groups can access ARV therapy daily, and not only after exposure, which will reduce their risk of infection. Committing to these new guidelines is a huge step in the right direction for South African health. It will allow for the best care of people living with HIV, ensuring that world-class methods are used to minimise the spread of HIV in the years to come. South African public hospitals began initiating this change in September 2016. What does this mean? A decade ago, the biggest challenge to successfully implementing HIV management through ARVs was the stigma associated with the virus and the severe side effects. Advancements in antiretroviral drug manufacturing have now made treatment more
34
– Dr Lerato Motshudi, AF Health
effective, with far fewer side effects. This will hopefully improve uptake and compliance on this treatment. Going forward, every person who tests HIV positive will receive additional counselling on treatment options right from the start. Every person with HIV can now receive ARV treatment and should have a conversation with their healthcare practitioner on how this process should be approached. In addition, prevention from contracting HIV for people who are at high risk, such as spouses of HIV-infected persons and men who have sex with men, is available in the form of a tablet taken daily. Public sector facilities started implementing this measure in September 2016. How does this affect how we look after employee health? Employees need to be made aware of this change in how HIV is treated so that if they or their loved ones require HIV therapy, they can get it without delay. To this end, all employee wellness programmes should consider including this education in their annual health communication calendars. Wellness specialists will need to make sure that their own staff and service providers have received the correct training, and processes and systems will also need to be amended appropriately. In the future, wellness programmes will have to provide HIV-related services to a larger number of employees, so the budget and the approach will have to be reviewed too. How does this affect me as an employee? If you need to speak to your doctor or any other health practitioner about your own treatment plan, take some time to read about HIV and the new treatment measures first. Doing so will improve your understanding and manage your expectations. If you don’t know your HIV status, go and get tested. Effective and convenient lifelong treatment is available and, if you test positive, starting ARV therapy without delay will improve your quality of life and prevent complications of having the disease. HIV is an easily diagnosable disease and can be safely and conveniently managed. Learn all that you can about how to ensure your good health.
HEALTH PRODUCT CHANGES 2017
A word on addiction
– Dr Lerato Motshudi, AF Health
Drug or substance abuse refers to a pattern of behaviour which leads a person to compulsively look for and use drugs, despite the negative impact that these drugs have on the individual and on their loved ones. People usually begin using drugs recreationally. However, over time, the body needs more of the drug to get the same ‘high’. This results in the individual taking more and more of their drug of choice until eventually the drug becomes a bad habit that’s very hard to quit. Some drugs are more addictive than others.
The danger of self-medicating When we think of drug addiction, street drugs such as dagga, cocaine or heroin come to mind, but in fact many people suffer from addiction to painkillers, antianxiety medication, and over-the-counter medication such as cough syrup containing codeine. Taking these legal drugs can lead to a good, sometime even euphoric, feeling. With repeated consumption, the body develops tolerance and you need more and more of the medication to get the same effect. Eventually taking the medicine will become a daily habit and, at this point, you are addicted. Addiction is when you cannot go without the drug, whatever it is. The uncontrollable urge or impulse to get the drug leads the addicted person to go to extreme lengths to get the drug, irrespective of the consequences. Drug addiction is commonly associated
with stealing, lying and broken relationships because of the compulsion to get money or make excuses to get more drugs. Why do some people become addicted while others don’t? Genetic predisposition is the most commonly known factor that increases the risk of addictive behaviour, but it’s not the only factor. The environment also plays a big part. A home with emotional, physical or sexual abuse, a neighbourhood where illegal drugs are easily accessible, or a circle of friends who use drugs are examples of environments that increase the risk of substance abuse. Individual behaviour, personality and personal choices also play a role. These markers influence will power and significantly affect how we are influenced by drugs – legal or otherwise.
35
ALEXANDER FORBES
How do I know I have a problem? The modified CAGE questionnaire helps you assess whether you have a problem with alcohol or drugs: ■■ Have you ever felt you ought to cut down on your drinking or drug use? ■■ Have people annoyed you by criticising your drinking or drug use? ■■ Have you ever felt bad or guilty about your drinking or drug use? ■■ Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
If you answered yes to two or more of the above questions, you may have a problem with addiction. How and where do I get help? Addiction doesn’t have to be a life sentence. You can turn things around. The first thing you need to do is get help and emotional support. Dealing with addiction cannot be accomplished on your own. Admit that you need help and find an accountability partner or ‘buddy’ who can support you as you get the help you need. Most employers and communities have platforms such as healthcare centres or anonymous helplines where you can reach out for direction on the best places to go to deal with addiction. Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) run 12-step programmes and attendance is free of charge.
It will be a good idea to remove yourself from social environments or people who hold you back on your road to recovery from addiction. How do I lead a normal life while dealing with my addiction? Addiction is a life-long condition. Once you have suffered from it, there will always be a danger that you could misuse drugs or other substances again in the future. The road to recovery is a daily effort. Make your journey easier by sticking to these three rules of thumb:
1
Talk to someone: Always have an accountability partner (‘buddy’) or group (AA/NA group, for example) that you can lean on for emotional support.
2
Stay away from what no longer serves you: Avoid high-risk environments that are likely to cause a relapse.
3
Take things one day at a time: If you stumble on your road to recovery, don’t give up.
Seek help immediately and get the support you need to get back on track. Addiction affects your emotional and mental health. It’s accompanied by depression, anxiety, relationship conflict and the inability to copy with the stresses of life. If you are suffering from addiction, dealing with the chemical problem alone is not enough. Get the emotional and psychological support you need to heal and be well again.
36
HEALTH PRODUCT CHANGES 2017
Embrace the benefits
of living healthy because your health matters!
It’s important to be financially fit, but it’s just as important to be healthy to enjoy your life to the fullest.
5
These five simple steps are all you need to improve your health now and into the future.
HEALTH BITE
STEP
1
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
According to the World Health Organization the most common medical conditions in old age are: ■■ musculoskeletal (arthritis and other joint problems) ■■ cardiovascular (heart disease, high blood pressure and stroke) ■■ mental illness (depression, stress related disorders) ■■ cancer ■■ chronic lifestyle conditions.
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.
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
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.
37
ALEXANDER FORBES
STEP
3
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 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
Step into the light! Being out in the sunshine produces vitamin D and improves the absorption of calcium. Just remember to put on sunscreen.
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
38
INDUSTRY
UPDATES
39
ALEXANDER FORBES
The role
of health insurance in meeting your medical needs
The public has a constitutional right to insure themselves against any financial risk, but often they are unaware of the subtle differences between a health insurance product and a medical scheme. The belief is that a health insurance policy offers the same protection as a medical scheme for major medical events, when in fact the protection is only partial and conditional.
In South Africa’s health sector, there is also no regulation which governs the tariffs charged to patients by health 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 a private specialist doctor and what is reimbursed by medical schemes. It is this uncertainty about what medical bills may arise in the future and what shortfalls may occur for a medical scheme member that has resulted in strong public support for health insurance cover, specifically hospital cash plans and gap cover products.
What is health insurance? A health insurance policy is a contract sold by an insurance company to an individual in terms of the Long-term Insurance Act or Short-term Insurance Act. It is subject to regulatory oversight 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 the age, health status and/ or income of the individual. For example, a policyholder who is a smoker or does a dangerous sport as a hobby would pay a higher premium for the same level of cover as another person of similar age. Specific types of exclusions may also be built into a policy, such as a maximum age at entry which excludes older people for cover, in particular retirees. 40
The Gap Cover policy is a specific type of shortterm health insurance designed to protect medical scheme members from costs not covered by medical scheme benefits. It pays the difference between the actual fees charged by health professionals (anaesthetists, surgeons, other specialists, GPs, and so on) and the medical scheme reimbursement tariff, for medical and surgical procedures done in hospital only, not out of hospital. A Hospital Cash Plan, however, targets nonmedical scheme members who wish to insure themselves against using the public sector. The policies are much more affordable in comparison to medical scheme 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 which don’t require an overnight stay in hospital, such as a burst appendix, may not be covered.
The Demarcation Regulations The draft demarcation regulations published by National Treasury specify the types of health insurance policies that are accepted under the Short-term and Long-term Insurance Acts. The intention of the regulations is to create a clear demarcation between health insurance and medical scheme business. The aim is to ensure that the design, marketing and sale of health insurance policies complement medical schemes without undermining the social solidarity principles of pooled contributions and open membership, while at the same time serving the needs of individuals who require additional financial protection against high medical expenses.
HEALTH PRODUCT CHANGES 2017
Proposed conditions for gap cover The second draft demarcation regulations, published for comment in April 2014, propose the following conditions on health insurance policies, and in particular on gap cover products.
Broker commission
Aligned to medical scheme commission. A drop to 3% of the policy premium from the current 20%.
Community rating
Policy premiums may not be based on age or health status.
Underwriting
No denial of benefits for pre-existing health events before policy commencement. Waiting periods may not exceed six months.
Policy benefit limits
A fixed rand amount which may not exceed R50 000 per event for gap cover and R3 000 per day for hospital cash plans.
Marketing
The terms ‘hospital’ or ‘medical’ cannot be used. Marketing material must state that the policy is not a substitute for a medical scheme.
Governance
Dual regulation by the Financial Services Board and the Council of Medical Schemes.
Public concerns and current position National Treasury received over 400 submissions last year during the consultation process on demarcation, a number of which were from individual members of the public urging government to keep gap cover. Some of the concerns raised in the submissions include: ■ The constitutionality for the proposals and the grounds for placing restrictions on health insurance in the absence of low-cost medical scheme alternatives. ■ Limitations on policy benefits are not enough to protect against expense shortfalls. ■ Realignment of commission is disproportionate to the advice and service obligations on accredited financial intermediaries. ■ Proposed underwriting terms and conditions are inadequate to protect against anti-selective behaviour and will undermine the affordability and sustainability of these products.
The numerous and extensive public comments received have resulted in the National Treasury and the Department of Health postponing the publication of the final Demarcation Regulations.
41
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. 42
HEALTH PRODUCT CHANGES 2017
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 43
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
44
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.
HEALTH PRODUCT CHANGES 2017
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 11705-Bonitas-DM-2016-10
45
ALEXANDER FORBES
Downloads
Option change form
Contribution rates for 2017
46