Evolving with you - CAMAF Medical · PDF fileAbout us The Chartered Accountants Medical Aid...

BENEFITS BROCHURE 2017

Evolving with you

About usThe Chartered Accountants Medical Aid Fund (CAMAF), which was established in 1951, was originally designed for accounting professionals and offers superior benefits to qualifying members. As the fund focuses on a niche market, it is able to provide a range of benefits that significantly surpass those offered by most open schemes. Always ahead of the curve, CAMAF strongly values innovation, and covers many procedures performed with the very latest technology. It also has a distinctly holistic focus, combining excellent healthcare benefits with an actively managed wellness programme. This is complemented by its loyalty programme, Multiply, which offers a range of attractive rewards for doing the everyday things that ensure a healthy and happy life. CAMAF is a trusted medical aid that gives its members peace of mind when it comes to the management of the scheme, as its Board of Trustees is made up of professionals who have a high regard for good corporate governance. They ensure that the delivery of excellent products and services is suitably balanced with sound reserves. While CAMAF provides cover mainly for companies, it also accepts individual members subject to certain approved qualifications (see Criteria for Individual Membership).

CAMAF Benefit Option Summary: Star Rating

Monthly Contribution Rates

Contact us

vital Essential Plus network Choice First Choice Double Plus Alliance

Hospital and Chronic

Day to Day - -

Preventative Wellness Benefits

-

MSA(savings) - - -

v EP n FC ADP

CAMAF Benefit Options: Quick Summary

vital Essential Plus network Choice First Choice Double Plus Alliance

Hospital Facility Fees Any private hospital Any private hospital Netcare hospitals only Any private hospital Any private hospital Any private hospital. Private wards

Attending Doctor's and Specialists in Hospital Up to 300% CBt Up to 200% CBt Up to 100% CBt Up to 100% CBt Up to 300% CBt Up to 300% CBt

Chronic condition cover: medicines and consults

63 Conditions 27 Conditions 27 Conditions 27 Conditions 63 Conditions 64 Conditions

Radiology and Pathology

Unlimited In or Out of Hospital

Unlimited In Hospital. Out of Hospital from MSA

Limits apply In and Outof hospital

Limits apply In and Outof hospital

Unlimited In or Outof Hospital

Unlimited In or Out of Hospital

Preventative Wellness Benefits 14 extra benefits 4 extra benefits 10 extra benefits 10 extra benefits 14 extra benefits 14 extra benefits

Day to Day Overall Limit (Principal Member)

- -

R2 840 for Medicines. R8 750 for Specialists.

R2 840 for Other.From DSP only

R2 840 for Medicines. R8 750 for Specialists.

R2 840 for Other.Paid at 80%

R11 000 R28 200

Medical Savings Account (Principal Member)

- R5 280 - - R4 056 R6 204

v EP n FC ADP

Benefit Option Quick Summary: vital

Any Private hospital: No limits

Attending Doctors and Specialists: Up to 300% of CBt

63 Chronic Conditions: Medication and consultations. Covers the medication and necessary consultations and procedures. Includes unlimited appropriate biological drugs and specialised technology as well as door to door medication delivery

unlimited X-Rays and Blood tests IN and OUT of hospital including MRI’s and CT’s

Screening Benefits

3 Month post hospitalisation benefit

External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor

Check-ups and vaccines: gP, Specialist, Dental, optometry, ECg

v

vitAlAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by

the legislation set out in the Regulations listed in the Medical Schemes Act.in hospital and Prescribed Minimum Benefits

hoSPitAl ACCoMMoDAtionINClUDINg CONFINEMENTS, SUBjECT TO PRE-AUTHORISATION 100% of negotiated Rate in general ward and specialised units

AttEnDing DoCtoRS AnD SPECiAliStSCONSUlTATIONS

MEDICAl AND SURgICAl PROCEDURES INClUDINg CONFINEMENTS SUBjECT TO PRE-AUTHORISATION

Up to 300% CBt 100% of Scheme Rate

SuPPlEMEntARy hEAlthCARE in hoSPitAl(Eg. PHySIOTHERAPy ANd PSyCHOTHERAPy) 100% CBt

BlooD tRAnSFuSionS(IN AND OUT OF HOSPITAl) 100% of cost

RADiology in hoSPitAlADvANCED SCANS (MRI/CT/PET)

SUBjECT TO PRE-AUTHORISATION

100% CBt100% CBt

PAthologyIN HOSPITAl 100% negotiated Rate

intERnAl PRoSthESiS SUBjECT TO PRE-AUTHORISATION 100% of cost

hoME nuRSing UP TO 21 dAyS, SUBjECT TO PRE-AUTHORISATION 100% CBt

StEP Down APPRovED FACilitiES (only, uP to 90 DAyS) SUBjECT TO PRE-AUTHORISATION 100% negotiated Rate

MEDiCAtionIN HOSPITAl 100% SEP plus dispensing fee

tto MEDiCAtionUP TO ONE WEEk’S SUPPLy 100% SEP plus dispensing fee

SuBStAnCE ABuSE PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days

ChRoniC PMB CDl MEDiCAtion AnD tREAtMEnt - SuBjECt TO PRE-AUTHORISATION AND PROTOCOlS

REFER to ChRoniC DiSEASE liSt100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DtP tREAtMEntOUT OF HOSPITAl TREATMENT SUBjECT TO REgISTRATION

OF CONDITION AND PRE-AUTHORISATIONMedication - SEP plus dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

onCology SUBjECT TO PRE-AUTHORISATION AND ICON PROTOCOlS#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 100% Scheme Rate. The ICON Core benefits apply

v

#Please refer to website for ICON benefit structures


the legislation set out in the Regulations listed in the Medical Schemes Act.Preventative wellness Cover

CAMAF liFEStylE PRogRAMMEPER AdULT BENEFICIARy

inCluDES: • Free health risk assessment at Clicks, dischem or Pick n Pay pharmacy • Access to e|Care portal with online wellness solutions to monitor your health and promote balanced, healthy living • Comprehensive wellness report plus personalised health articles in weekly emails when you complete your wellness assessment online.

onE gP ConSultAtion onlyiCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy 100% CBt per beneficiary

onE SPECiAliSt ConSultAtion iCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy.

gyNAECOLOgISTS, UROLOgISTS, OR SPECIALIST PHySICIANS**FOR BENEFICIARIES OvER 16 yEARS. PAEDIATRICIANS FOR

BENEFICIARIES UNdER 16 yEARS

100% CBt per beneficiary

PSyChothERAPy 100% CBt limited to R10 140 per beneficiaryonE DiEtiCiAn ConSultAtion 100% CBt per beneficiary

onE DEntiStRy ConSultAtiongENERAL CHECk UP ONLy - ExCLUdES CONSUMABLES 100% CBt per beneficiary

onE ECg(PERFORMEd By gP OR SPECIALIST PHySICIAN**)

iCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy- ExCLUdES CONSUMABLES

100% CBt per adult beneficiary

onE oPtoMEtRiSt ConSultAtion Within the PPN Network: 100% of cost for a composite consultation inclusive of the refraction,a glaucoma screening, and visual field screening. Outside of the PPN Network: 100% Optical Assistant Rates

MEtABoliC SCREEning FoR nEw BoRn BABiES 100% negotiated Rate per new born babyiMMuniSAtion AnD vACCinES

(COST OF IMMUNISATION ANd vACCINE ONLy SEP plus a dispensing fee, limited to R1 480 per beneficiary

CERviCAl CAnCER vACCinE(COST OF vACCINE ONLy)

Females between 9 and 16 years of age(SEP plus dispensing fee)

onE hiv vCt tESt 100% cost per beneficiaryMElAnoMA SCREEning tESt 100% CBt per adult beneficiary

uMBiliCAl StEM CEll hARvESting

Negotiated discount with Cryo-Save. notE: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits.

v

**Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like Pulmonologists or gastroenterologists.


the legislation set out in the Regulations listed in the Medical Schemes Act.other Benefits (Per Beneficiary) not Subject to the Annual overall Benefit limit

BASiC AnD ADvAnCED RADiologyOUT OF HOSPITAl

MUST BE PERFORMEd By A REgISTEREd RAdIOLOgIST, ON REFERRAL FROM MEdICAL PRACTITIONER ONLy. AdvANCEd

SCANS (MRI/CT/PET) SUBjECT TO PRE-AUTHORISATION

100% CBt

PAthologyOUT OF HOSPITAl

PERFORMEd By A REgISTEREd PATHOLOgIST ANd REFERREd By A MEdICAL PRACTITIONER

PRE-AUTHORISATION REQUIREd FOR AdvANCEd PATHOLOgy

100% negotiated Rate or CBt

PoSt-hoSPitAliSAtion CONSULTATIONS ANd TREATMENT UP TO 90 dAyS

300% CBt for attending practitioners100% CBt for auxiliary services

MEDiCAtion FoR ADDitionAl ChRoniC ConDitionS(SUBjECT TO PRE-AUTHORISATION) REFER TO

ADDitionAl ChRoniC ConDitionS liSt

100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBt

EXtERnAl APPliAnCES IN AND OUT OF HOSPITAl - PURCHASE, HIRE AND

MAINTENANCEHEARINg AIdS - 1 CLAIM PER 3 yEAR

CyCLE FOR OvER 16 yEARS OF AgE, yOUNgER THAN 16 yEARS OF AgE - 18 MONTH CyCLE

WHEELCHAIRS - 3 yEAR CyCLEINSUlIN PUMPS, SUBjECT TO

PRE-AUTHORISATION ANd dSP - 4 yEAR CyCLEBREAST PUMPS AND APNOEA MONITORS - THREE MONTHS

PRIOR TO ExPECTEd dUE dATE ANd WITHIN SIx MONTHS AFTER THE BIRTH OF THE BABy. SUBjECT TO REgISTRATION ON

THE MOTHER TO BE PROgRAMME

100% of cost subject to the overall limit of R 34 300 per beneficiary and subject to the following sub-limits:

Hearing Aids: R29 700Wheelchairs for Quadriplegics: R29 700Standard Wheelchairs: R20 900Insulin Pumps: R34 300Other external appliances: R 7 500• Baby Apnoea monitors: R 2 300• Breast pumps: R 3 800

intERnAtionAl tRAvEl CovERR10 million per beneficiary per journey for emergency medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa. Pre-existing conditions are excluded.

nEtCARE 911 EMERgEnCy SERviCES Unlimited - Subject to Netcare 911 authorisation

v

total Monthly ContributionAdult R1 991Child R1 038

Monthly Contribution Rates: vital

v

Benefit Option Quick Summary: Essential Plus


Attending Doctors and Specialists: Up to 200% of CBt

27 Chronic Conditions: Medication and consultations

unlimited X-Rays and Blood tests IN hospital including MRI and CT scans

Screening Benefits

Psychotherapy and Immunisation Benefits

EP

ESSEntiAl PluSAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by










100% CBt100% CBt













Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - 100% DSP Tariff. The DSP is the ICON network. The ICON Essential benefits apply


EP

Preventative wellness Cover



onE gP ConSultAtion onlyiCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy Subject to Medical Savings Account




Subject to Medical Savings Account

PSyChothERAPy 100% CBt limited to R10 140 per beneficiaryonE DiEtiCiAn ConSultAtion Subject to Medical Savings Account

onE DEntiStRy ConSultAtiongENERAL CHECk UP ONLy - ExCLUdES CONSUMABLES Subject to Medical Savings Account


iCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy - ExCLUdES CONSUMABLES


onE oPtoMEtRiSt ConSultAtion Subject to Medical Savings AccountMEtABoliC SCREEning FoR nEw BoRn BABiES Subject to Medical Savings Account

iMMuniSAtion AnD vACCinES(COST OF IMMUNISATION ANd vACCINE ONLy) SEP plus a dispensing fee, limited to R1 480 per beneficiary



onE hiv vCt tESt Subject to Medical Savings AccountMElAnoMA SCREEning tESt Subject to Medical Savings Account


Negotiated discount with Cryo-Save. note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits.


the legislation set out in the Regulations listed in the Medical Schemes Act.


EP

EP

other Benefits (Per Beneficiary) not Subject to the Annual overall Benefit limitBASiC AnD ADvAnCED RADiology

OUT OF HOSPITAlMUST BE PERFORMEd By A REgISTEREd RAdIOLOgIST, ON

REFERRAL FROM MEdICAL PRACTITIONER ONLy.ADvANCED SCANS (MRI/CT/PET) SUBjECT TO PRE-

AUTHORISATION






PoSt-hoSPitAliSAtion CONSULTATIONS ANd TREATMENT UP TO 90 dAyS Subject to Medical Savings Account


ADDitionAl ChRoniC ConDitionS liStSubject to Medical Savings Account except for depression













EP

other Benefits (Per Beneficiary) Subject to the Annual overall Day-to-Day Benefit limitDAy to DAy BEnEFitS

BENEFITS BElOW ARE SUBjECT TO THE OvERAll ANNUAl lIMIT

Limited to funds available in the beneficiary’s Medical Savings Account

gP’S AnD DEntiStSdENTAL x-RAyS PERFORMEd By dENTISTS,

CONSULTATIONS ANd PROCEdURES PERFORMEd By THESE PRACTITIONERS; BASIC dENTISTRy


SPECiAliStSCONSULTATIONS, PROCEdURES ANd RAdIOLOgy

PERFORMEd By THESE PRACTITIONERSSubject to Medical Savings Account

ACutE MEDiCAtionINClUDINg INjECTIONS AND MATERIAlS Subject to Medical Savings Account

CASuAlty AnD out PAtiEnt tREAtMEnt At A hoSPitAl All MEDICATIONS WIll BE PAID OUT OF ACUTE MEDICATION

BENEFITSubject to Medical Savings Account

nuRSE viSitS Subject to Medical Savings AccountSuPPlEMEntARy hEAlth

AUdIOLOgy, CHIROPRACTORS, dIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPy, PHySIOTHERAPISTS, BIOkINETICISTS,

POdIATRy ANd SPEECH THERAPy


ADvAnCED DEntiStRyCROWNS, BRIDgES, ORTHODONTICS, DENTURES Subject to Medical Savings Account

ovER thE CountER MEDiCAtion Subject to Medical Savings AccountlASER K

NO APPROvAL FOR SURgERy WHERE SPECTACLES OBTAINEd IN PREvIOUS 12 MONTHS

IF THE lASER K BENEFIT IS UTIlISED, NO SPECTAClE AND CONTACT LENSE BENEFIT ALLOWEd FOR 2 yEARS


AntE-nAtAl FoEtAl SCAnSPER PREgNANCy Subject to Medical Savings Account

AntE-nAtAl ClASSES Subject to Medical Savings AccountSPECtAClES AnD lEnSES

FROM OPTOMETRIST ONLy ANNUAL BENEFIT, UNLESS OTHERWISE STATED




Monthly Contribution Rates: Essential Plus

Monthly Risk ContributionPrincipal R1 500Adult R1 190Child R 700

Monthly MSA ContributionPrincipal R 440Adult R 351Child R 206

total Monthly ContributionPrincipal R1 940Adult R1 541Child R 906

EP

Benefit Option Quick Summary: network Choice

network hospital: No limits (DSP hospital group is Netcare)

Attending Doctors: Up to 100% CBt only at DSP

27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and specialised technology and door to door medication delivery

X-Rays and Blood tests Advanced scans limited to R32 800 per family

Screening Benefits

vaccines

n

nEtwoRK ChoiCEAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by


hoSPitAl ACCoMMoDAtionINClUDINg CONFINEMENTS, SUBjECT TO PRE-AUTHORISATION 100% DSP tariff as per protocols. The DSP hospital group is Netcare.



Up to 100% CBt 100% of CBt





100% CBt100% CBt limited to R32 800 per family

PAthologyIN HOSPITAl 100% CBt

intERnAl PRoSthESiS SUBjECT TO PRE-AUTHORISATION 100% of cost limited to R32 800 per family

hoME nuRSing UP TO 21 dAyS, SUBjECT TO PRE-AUTHORISATION 100% CBt (in lieu of hospitalisation only)

StEP Down APPRovED FACilitiES (only, uP to 90 DAyS) SUBjECT TO PRE-AUTHORISATION 100% DSP Tariff





REFER to ChRoniC DiSEASE liSt100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - at cost


OF CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures- at cost


Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - 100% DSP Tariff. The DSP is the ICON network. The ICON Essential benefits apply


n

n




onE gP ConSultAtion onlyiCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy 100% CBt per beneficiary (Network doctor only)





PSyChothERAPy 100% CBt limited to R10 140 per beneficiaryonE DEntiStRy ConSultAtion

gENERAL CHECk UP ONLy - ExCLUdES CONSUMABLES 100% CBt per beneficiary (Network dentist only)


iCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy - ExCLUdES CONSUMABLES


onE oPtoMEtRiSt ConSultAtion Refer to spectacle and lenses benefitsMEtABoliC SCREEning FoR nEw BoRn BABiES 100% negotiated Rate per new born baby

iMMuniSAtion AnD vACCinES(COST OF IMMUNISATION ANd vACCINE ONLy) SEP plus a dispensing fee, subject to MMAP, limited to R1 480 per beneficiary



onE hiv vCt tESt 100% CBt per beneficiary






n



REFERRAL FROM MEdICAL PRACTITIONER ONLy.ADvANCED SCANS (MRI/CT/PET) SUBjECT TO

PRE-AUTHORISATION

Basic Radiology: Referrals by DSP or specialist, 100% CBt limited to R3 830 per beneficiaryAdvanced scans: 100% CBt limited to R32 800 per family (referral by DSP or specialist)




Referred by DSP or specialist, 100% CBt, limited to R6 120 per beneficiary


ADDitionAl ChRoniC ConDitionS liStNo Benefit except for depression








100% of cost limited of R5 900 per beneficiary and subject to DSP or Specialist referral and subject to the following sub-limits:

• Baby Apnoea monitors: R2 000 • Breast pumps: R3 400





n


the legislation set out in the Regulations listed in the Medical Schemes Act.other Benefits (Per Beneficiary) Subject to the Annual overall Day-to-Day Benefit limit

DAy to DAy BEnEFitSBENEFITS BElOW ARE SUBjECT TO THE OvERAll ANNUAl lIMIT

Annual overall limit: Beneficiary specific limits:(a) Medicines R 2 840(b) Advanced Dentistry R 5 950(c) Other R 2 840(d) Specialists R 8 750

gP’S AnD DEntiStSdENTAL x-RAyS PERFORMEd By dENTISTS, CONSULTATIONS ANd

PROCEdURES PERFORMEd By THESE PRACTITIONERS; BASIC dENTISTRy

100% negotiated rate at a network provider only subject to sublimit (c)

SPECiAliStSCONSULTATIONS, PROCEdURES ANd RAdIOLOgy PERFORMEd

By THESE PRACTITIONERS

100% CBtSubject to limit (d) (on referral from a network gP only)

ACutE MEDiCAtionINClUDINg INjECTIONS AND MATERIAlS 100% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) (on referral from a network gP only)

non-DSP viSitSTO DOCTORS’ ROOMS

One non-network visit per beneficiary or two per family, 20% co-paymentANDOne casualty visit per family (facility fee, consumed meds and materials).Limited to R 1 310Associated claims such as radiology and pathology are not covered unless it is a PMB or DtP.


BENEFITnuRSE viSitS 100% CBt subject to limit (c)

SuPPlEMEntARy hEAlthAUdIOLOgy, CHIROPRACTORS, dIETICIANS, HOMOEOPATHS,

OCCUPATIONAL THERAPy, PHySIOTHERAPISTS, BIOkINETICISTS, POdIATRy ANd SPEECH THERAPy

100% CBt limited to R2 380 per beneficiary on referral from DSP or from a Specialist.Subject to limit (c)

BEnEFit SPECiFiC liMitSADvAnCED DEntiStRy

CROWNS, BRIDgES, ORTHODONTICS, DENTURES100% of CBtSubject to limit (b) excluding dental implants

ovER thE CountER MEDiCAtion 80% SEP plus a dispensing fee, subject to MMAP, limited to R1 460 per beneficiary. Subject to limit (a)AntE-nAtAl FoEtAl SCAnS

PER PREgNANCy 3 scans at 80% CBt. Subject to limit (c)

AntE-nAtAl ClASSES 80% CBt subject to sub-limit R910 per pregnancy Subject to limit (c)

SPECtAClES AnD lEnSESFROM OPTOMETRIST ONLy ANNUAL BENEFIT, UNLESS

OTHERWISE STATED

The benefit PER BENEFICIARY at a PPN provider would be as follows:For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to:One Composite Consultation inclusive of a Refraction, Tonometry and Visual Field screening AND EithER SPECtAClES - A PPN Frame to the value of R150 or R600 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR ContACt lEnSES - Contact lenses to the value of R800.

The benefit PER BENEFICIARY at a NON PPN provider would be as follows:One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R715 AND EithER SPECtAClES - A frame benefit of R600 towards the cost of a frame and/or lens enhancements and one pair of lenses: either one pair of clear single vision spectacle lenses limited to R165 per lens or one pair of clear flat top bifocal spectacle lenses limited to R360 per lens or one pair of clear flat top Multifocal lenses limited to R660 per lens OR ContACt lEnSES - Contact Lenses to the value of R800.

Monthly Contribution Rates: network Choice

R 0 - R15 660

Principal R1 280Adult R1 0701st Child(rest are free) R 555

R15 661 - R21 000

Principal R1 520Adult R1 2101st Child(rest are free) R 683

R21 001 - R31 500Principal R1 815Adult R1 405Child R 905Principal R2 410

R31 501 + Adult R1 945Child R1 183

n

Benefit Option Quick Summary: First Choice


Attending Dr’s and Specialists: Up to 100% CBt

27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and specialised technology and door to door medication delivery

X-Rays and Blood tests Advanced scans limited to R32 800 per family

Screening Benefits

80% of GP, Specialists, Dental, Optometry, Check-ups, ECG, Vaccines

FC

in hospital and Prescribed Minimum BenefitshoSPitAl ACCoMMoDAtion

INClUDINg CONFINEMENTS, SUBjECT TO PRE-AUTHORISATION

100% of negotiated Rate in general ward and specialised units

AttEnDing DoCtoRS AnD SPECiAliStSCONSUlTATIONS MEDICAl AND SURgICAl PROCEDURES

INClUDINg CONFINEMENTS SUBjECT TO PRE-AUTHORISATION

Up to 100% CBt 100% CBt



RADiology IN HOSPITAlADvAnCED SCAnS (MRi/Ct/PEt)


100% CBt100% CBt limited to R32 800 per family

PAthologyIN HOSPITAl 100% CBt

intERnAl PRoSthESiS SUBjECT TO PRE-AUTHORISATION 100% of cost limited to R32 800 per family

hoME nuRSing UP TO 21 dAyS, SUBjECT TO PRE-AUTHORISATION 100% CBt (in lieu of hospitalisation only)





ChRoniC PMB CDl MEDiCAtionAnD tREAtMEnt - SuBjECt to PRE-AuthoRiSAtion AnD PRotoColS



OF CONDITION AND PRE-AUTHORISATION

Medication - SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

onCology SUBjECT TO PREAUTHORISATION AND ICON PROTOCOlS#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - 100% dSP Tariff. The dSP is the ICON Network. The ICON Essential benefits apply

FiRSt ChoiCEAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by


FC


FC









PSyChothERAPy 100% CBt limited to R10 140 per beneficiaryonE DEntiStRy ConSultAtion

gENERAL CHECk UP ONLy - excludes consumables 100% CBt per beneficiary


iCD 10 CoDE SPECIFIC TO gENERAL CHECk UP ONLy - excludes consumables


onE oPtoMEtRiSt ConSultAtion Refer to spectacle and lenses benefitsMEtABoliC SCREEning FoR nEw BoRn BABiES 100% negotiated Rate per new born baby

iMMuniSAtion AnD vACCinES(COST OF IMMUNISATION ANd vACCINE ONLy) SEP plus a dispensing fee, subject to MMAP, limited to R1 480 per beneficiary



onE hiv vCt tESt 100% CBt per beneficiary



FiRSt ChoiCEAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by



FC

FiRSt ChoiCEAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the

Medical Schemes Act.




AUTHORISATION

Basic Radiology: 100% CBt limited to R3 830 per beneficiaryAdvanced scans: 100% CBt limited to R32 800 per family




100% CBt limited to R6 120 per beneficiary


ADDitionAl ChRoniC ConDitionS liStNo Benefit except for depression








100% of cost in hospital and 80% of cost out of hospital with an overall limit of R5 900 per beneficiary and subject to the following sub-limits:

• Baby Apnoea monitors: R2 000 • Breast pumps: R3 400



FC

other Benefits (Per Beneficiary) Subject to the Annual overall Day-to-Day Benefit limit


Annual overall limit: Beneficiary specific limits:(a) Medicines R2 840(b) Advanced Dentistry R5 950(c) Other R2 840(d) Specialists R8 750



80% CBtSubject to limit (c)


By THESE PRACTITIONERS

80% CBtSubject to limit (d)

ACutE MEDiCAtionINClUDINg INjECTIONS AND MATERIAlS 80% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a)


BENEFIT

Medication: 80% SEP plus a dispensing fee subject to limit (a)Treatment: 80% CBt subject to limit (c)

nuRSE viSitS 80% CBt subject to limit (c)SuPPlEMEntARy hEAlth



80% CBt subject to sub-limit R2 380Subject to limit (c)

BEnEFit SPECiFiC liMitSADvAnCED DEntiStRy

CROWNS, BRIDgES, ORTHODONTICS, DENTURES50% CBtSubject to limit (b) excluding dental implants

ovER thE CountER MEDiCAtion 80% SEP plus a dispensing fee, subject to MMAP, limited to R1 460 per beneficiary. Subject to limit (a)AntE-nAtAl FoEtAl SCAnS

PER PREgNANCy 3 scans at 80% CBt. Subject to limit(c)

AntE-nAtAl ClASSESSUBjECT TO ENROlMENT ON THE MOTHER-TO-BE PROgRAMME

80% CBt subject to sub-limit R910 per pregnancySubject to limit (c)


OTHERWISE STATED

The benefit PER BENEFICIARY at a PPN provider would be as follows:For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to:One Composite Consultation inclusive of a Refraction, Tonometry and Visual Field screening AND EithER SPECtAClES - A PPN Frame to the value of R150 or R600 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR ContACt lEnSES - Contact lenses to the value of R800.

The benefit PER BENEFICIARY at a NON PPN provider would be as follows:One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R715 AND EithER SPECtAClES - A frame benefit of R600 towards the cost of a frame and/or lens enhancements and one pair of lenses: either one pair of clear single vision spectacle lenses limited to R165 per lens or one pair of clear flat top bifocal spectacle lenses limited to R360 per lens or one pair of clear flat top Multifocal lenses limited to R660 per lens OR ContACt lEnSES - Contact Lenses to the value of R800.

FiRSt ChoiCEAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the

Medical Schemes Act.

income Category total Monthly Contribution

R 0 - R8 110Adult R 870Child R 530

R8 111 - R15 660Adult R1 380Child R 820

R15 661 - R21 000Adult R2 065Child R1 205

R21 001 - R31 500Adult R2 565Child R1 685

R31 501 +Adult R2 800Child R1 825

Monthly Contribution Rates - First Choice

FC

Benefit Option Quick Summary: Double Plus

DP



63 Chronic Conditions Medication and Consultations. Includes unlimited appropriate Biological Drugs and Specialised Technology

unlimited X-rays and Blood tests In and Out of Hospital including MRI and CT Scans

Screening Benefit

3 Month Post Hospitalisation Benefit

External Appliances: wheelchair, hearing aid, breast pump, baby sleep monitor

Check-ups and vaccines: GP, Specialist, Dental, Optometry, ECG

infertility R52 100 per family

DouBlE PluSAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by










100% CBt100% CBt







inFERtility tREAtMEnt Treatment limited to R52 100 per family







Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 100% Scheme Rate. The ICON Core benefits apply


DP










onE DEntiStRy ConSultAtiongENERAL CHECk UP ONLy - excludes consumables 100% CBt per beneficiary




onE oPtoMEtRiSt ConSultAtionWithin the PPN Network: 100% of cost for a composite consultation inclusive of the refraction, a glaucoma screening, and visual field screening.Outside of the PPN Network: 100% Optical Assistant Rates


(COST OF IMMUNISATION ANd vACCINE ONLy) SEP plus a dispensing fee, limited to: Adults R2 220 - Child R3 690



onE hiv vCt tESt 100% CBt per beneficiaryMElAnoMA SCREEning tESt 100% CBt per adult beneficiary



DP




DP




AUTHORISATION

100% CBt

PAthologyOUT OF HOSPITAL - PERFORMEd By A REgISTEREd

PATHOLOgIST ANd REFERREd By A MEdICAL PRACTITIONERPRE-AUTHORISATION REQUIREd FOR AdvANCEd PATHOLOgy














100% of cost subject to the overall limit of R 59 500 per beneficiary and subject to the following sub-limits:Hearing Aids: R59 500Wheelchairs for Quadriplegics: R59 500Standard Wheelchairs: R38 000Insulin Pumps: R38 800Other external appliances: R12 700 • Baby Apnoea monitors: R 2 300 • Breast pumps: R 3 800





DP



Annual Overall LimitsAdult R11 000Child R 7 700



80% CBt


By THESE PRACTITIONERS80% CBt

ACutE MEDiCAtionINClUDINg INjECTIONS AND MATERIAlS 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA


BENEFIT80% CBt

nuRSE viSitS 80% CBt up to 21 daysSuPPlEMEntARy hEAlth



80% CBt

ADvAnCED DEntiStRyCROWNS, BRIDgES, ORTHODONTICS, DENTURES

80% CBt limited to:Mo R11 000M1 R15 800M2+ R21 300

ovER thE CountER MEDiCAtion 80% SEP plus a dispensing fee subject to MMAP, co-payment from MSA, limited to R1 600 per beneficiarylASER K

NO APPROvAL FOR SURgERy WHERE SPECTACLES OBTAINEd IN PREvIOUS 12 MONTHS IF THE lASER K BENEFIT IS UTIlISED, NO

SPECTACLE ANd CONTACT LENSE BENEFIT ALLOWEd FOR 2 yEARS

80% CBt limited to R4 140 per eye

AntE-nAtAl FoEtAl SCAnSPER PREgNANCy 4 Scans at 80% CBt

AntE-nAtAl ClASSES 80% CBt limited to R1 640 per pregnancy


OTHERWISE STATED

Consultation: See Preventative Wellness Benefit per beneficiary at a PPN PROvIdER:EITHER: R3 500 for frames and/or lens enhancementsOR: Contact lenses to the value of R3 400. PPN Rates applyBenefit per beneficiary at a NON-PPN PROvIdER, FUNdEd AT 80% of Optical Assistant Rates:EITHER: R3 500 for frames and/or lens enhancements plus clear lenses.The following sub-limits apply to lenses:Single vision: R950Bifocal: R2 550varifocal: R3 910OR: Contact lenses to the value of R3 400Co-payments from MSA. ALL BENEFITS ANd CLAIMS MANAgEd By PPN



Monthly Contribution Rates - Double Plus

DP

Monthly Risk ContributionAdult R3 033Child R1 742

Monthly MSA ContributionAdult R 338Child R 214


Benefit Option Quick Summary: Alliance

AlliAnCE

Any Private hospital: No limits, private wards for confinements (subject to availability)


64 Chronic Conditions medication and consultations. Includes unlimited appropriate biological drugs and specialised technology

unlimited X-Rays and Blood tests IN and OUT of hospital including MRI and CT scans

Screening Benefit

3 Month post hospitalisation benefit

External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor

Check-ups and vaccines: GP, Specialist, Dental, Optometry, Dermatologist, ECG, Dietician

infertility R74 500 per family

A

AlliAnCEAll benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by


hoSPitAl ACCoMMoDAtionINClUDINg CONFINEMENTS, SUBjECT TO PRE-AUTHORISATION

100% of negotiated Rate in general ward and specialised units. Private wards for confinements (subject to availability)








100% CBt100% CBt







inFERtility tREAtMEnt Treatment limited to R74 500 per family







Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 100% Scheme Rate. The ICON Enhanced benefits apply


A

A










onE DEntiStRy ConSultAtiongENERAL CHECk UP ONLy - excludes consumables 100% CBt per beneficiary




onE oPtoMEtRiSt ConSultAtionWithin the PPN Network: 100% of cost for a composite consultation inclusive of the refraction, a glaucoma screening, and visual field screening.Outside of the PPN Network: 100% Optical Assistant Rates


(COST OF IMMUNISATION ANd vACCINE ONLy) SEP plus a dispensing fee, limited to R4 450 per beneficiary



onE hiv vCt tESt 100% CBt per beneficiaryMElAnoMA SCREEning tESt 100% CBt per adult beneficiary






A




AUTHORISATION

100% CBt

PAthologyOUT OF HOSPITAL - PERFORMEd By A REgISTEREd

PATHOLOgIST ANd REFERREd By A MEdICAL PRACTITIONERPRE-AUTHORISATION REQUIREd FOR AdvANCEd PATHOLOgy














100% of cost subject to the overall limit of R74 500 per beneficiary and subject to the following sub-limits:Hearing Aids: R74 500Wheelchairs for Quadriplegics: R74 500Standard Wheelchairs: R44 600Insulin Pumps: R44 600Other external appliances: R14 900 • Baby Apnoea monitors: R 2 300 • Breast pumps: R 3 800





A



Annual Overall LimitsAdult R28 200Child R17 700



80% CBt


By THESE PRACTITIONERS80% CBt

ACutE MEDiCAtionINClUDINg INjECTIONS AND MATERIAlS 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA


BENEFIT80% CBt

nuRSE viSitS 80% CBt up to 21 daysSuPPlEMEntARy hEAlth



80% CBt

ADvAnCED DEntiStRyCROWNS, BRIDgES, ORTHODONTICS, DENTURES

80% CBt limited to:Mo R14 800M1 R22 100M2+ R26 500

ovER thE CountER MEDiCAtion 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R 3 700 per beneficiarylASER K

NO APPROvAL FOR SURgERy WHERE SPECTACLES OBTAINEd IN PREvIOUS 12 MONTHS IF THE lASER K BENEFIT IS UTIlISED, NO

SPECTACLE ANd CONTACT LENSE BENEFIT ALLOWEd FOR 2 yEARS

80% CBt limited to R11 155 per eye

AntE-nAtAl FoEtAl SCAnSPER PREgNANCy 6 Scans at 80% CBt

AntE-nAtAl ClASSES 80% CBt limited to R2 230 per pregnancy


OTHERWISE STATED

Consultation: See Preventative Wellness Benefit per beneficiary at a PPN PROvIdER:EITHER: R6 500 for frames and/or lens enhancementsOR: Contact lenses to the value of R6 320. PPN Rates applyBenefit per beneficiary at a NON-PPN PROvIdER, FUNdEd AT 80% of Optical Assistant Rates:EITHER: R6 500 for frames and/or lens enhancements plus clear lenses.The following sub-limits apply to lenses:Single vision: R1 450Bifocal: R2 900varifocal: R4 360OR: Contact lenses to the value of R6 320Co-payments from MSA. ALL BENEFITS ANd CLAIMS MANAgEd By PPN



Monthly Contribution Rates - Alliance

Monthly Risk ContributionAdult R4 582Child R2 499

Monthly MSA ContributionAdult R 517Child R 240


A

http://www.camaf.co.za/products/products_calculator.htmlclick here

to link to our online calculator

Monthly Contribution Rates

AlliAnCEDouBlEPluSvitAl FiRSt

ChoiCE

TotalMonthly Contribution

nEtwoRKChoiCE

total Monthly Contribution

Adult R1 991Child R1 038

Monthly Risk Contribution

Principal R1 500Adult R1 190Child R 700

Monthly MSA Contribution

Principal R 440Adult R 351Child R 206


Principal R1 940Adult R1 541Child R 906

Income Category

R 0 - R15 660Principal R1 280Adult R1 0701st Child R 555(rest are free)

R15 661 - R21 000Principal R1 520Adult R1 210Child R 683(rest are free)

R21 001 - R31 500Principal R1 815Adult R1 405Child R 905

R31 501+Principal R2 410Adult R1 945Child R1 183

IncomeCategory

R0 - R 8 110Adult R 870Child R 530

R8 111 - R15 660Adult R1 380Child R 820

R15 661 - R21 000Adult R2 065Child R1 205

R21 001 - R31 500 Adult R2 565Child R1 685

R31 501+Adult R2 800Child R1 825




Adult R 338Child R 214






Adult R 517Child R 240



v AEP DPn FCESSEntiAlPluS

Chronic Disease list - PMB CDl Conditions - All OptionsCondition Consultations level of Consultation Cover

ADDISON’S DISEASE general Practitioner (gP), Physician, Paediatrician, Endocrinologist 100% COST

ASTHMA* gP, Physician, Pulmonologist, Paediatrician, Physiotherapist 100% COST

BIPOlAR MOOD DISORDER* Psychiatrist, Clinical Psychologist, Social Worker 100% COST

BRONCHIECTASIS* gP, Physician, Pulmonologist, Physiotherapist 100% COST

CARDIAC FAIlURE gP, Physician, Cardiologist, Dietician 100% COST

CARdIOMyOPATHy gP, Physician, Cardiologist, Dietician 100% COST

CHRONIC OBSTRUCTIvE PULMONARy dISORdER (COPd)* gP, Physician, Pulmonologist, Physiotherapist 100% COST

CHRONIC RENAl DISEASE gP, Physician, Urologist, Dietician 100% COST

CORONARy ARTERy dISEASE gP, Physician, Cardiologist, Dietician 100% COST

CROHN’S DISEASE gP, gastroenterologist, Dietician, Physician 100% COST

DIABETES INSIPIDUS gP, Physician, Urologist, Paediatrician, Endocrinologist 100% COST

dIABETES MELLITUS (TyPE 1 ANd TyPE 2)* gP, Physician, Paediatrician, Ophthalmologist, dietician, Podiatrist, Endocrinologist 100% COST

dySRHyTHMIA gP, Physician, Cardiologist, Paediatrician 100% COST

EPILEPSy gP, Physician, Neurologist, Occupational Therapist, Speech Therapist, Physiotherapist, Paediatrician 100% COST

glAUCOMA gP, Physician, Ophthalmologist 100% COST

HAEMOPHIlIA A & B gP, Physician, Paediatrician, Haematologist 100% COST

HIv/AIDS** gP, Physician, Paediatrician 100% COST

HyPERLIPIdAEMIA* gP, Physician, Cardiologist, Paediatrician, Dietician 100% COST

HyPERTENSION* gP, Physician, Cardiologist, Dietician 100% COST

HyPOTHyROIdISM gP, Physician, Paediatrician 100% COST

MUlTIPlE SClEROSIS gP, Physician, Neurologist, Ophthalmologist, Urologist, Occupational Therapist, Physiotherapist 100% COST

PARKINSON’S DISEASE gP, Physician, Neurologist 100% COST

RHEUMATOID ARTHRITIS gP, Physician, Ophthalmologist, Orthopaedics, Rheumatologist, Paediatrician 100% COST

SCHIZOPHRENIA* Psychiatrist, Clinical Psychologist, Social Worker, Occupational Therapist 100% COST

SySTEMIC LUPUS ERyTHEMATOSIS gP, Physician, dermatologist, Paediatrician, Rheumotologist 100% COST

UlCERATIvE COlITIS gastroenterologist, dietician, gP, Physician, Rheumotologist 100% COST

In terms of the Medical Schemes Act Regulations that came into effect on 1 january 2004, Medical Schemes are required to fund the cost of the diagnosis, medical management (consultations and procedures) and medication of the specified list of chronic conditions. All of these conditions are covered by CAMAF*Subject to registration on relevant Wellness Programme**Subject to registration with LifeSense

Chronic Disease list - Additional Chronic Conditions- Alliance, Double Plus and vital options

Condition Consultations level of Consultation CoverADHD (Alliance only) Paediatrician, Neurologist, Psychiatrist 100% CBTAllERgIC RHINITIS gP, Ear Nose and Throat Specialist (ENT), Paediatrician 100% CBTAlZHEIMER’S DISEASE Neurologist, Psychiatrist 100% CBTANkyLOSINg SPONdyLITIS Physician, Rheumatologist 100% CBTBENIgN PROSTATIC HyPERTROPHy Urologist 100% CBTCHRONIC gRANUlOMATOUS DISEASE Physician 100% CBTCOAgUlATION DISORDERS Cardiologist, Physician, Clinical Haemotologist 100% CBTCONgENITAl HEART MAlFORMATIONS Physician, Cardiologist, Paediatrician 100% CBTCySTIC FIBROSIS Physician, Physiotherapist, Pulmonologist, Paediatrician, gP 100% CBTDEEP vEIN THROMBOSIS Physician 100% CBTDEPRESSION (includes First Choice and Essential Plus) gP, Psychiatrist, Clinical Psychologist, Social Worker 100% CBTECZEMA dermatologist, gP 100% CBTENDOMETRIOSIS gynaecologist 100% CBTgASTRO-OESOPHAgEAL REFLUx dISEASE (gORd) gP, gastroenterologist, Physician, Paediatrician 100% CBTgAUCHERS DISEASE Physician, Paediatrician 100% CBTgOUT PROPHyLAxIS gP 100% CBTHORMONE REPlACEMENT gP 100% CBTHyPERPARATHyROIdISM Physician 100% CBTHyPERTHyROIdISM gP, Paediatrician 100% CBTMENIERE’S DISEASE gP, Ear Nose and Throat Specialist (ENT) 100% CBTMIgRAINE PROPHyLAxIS gP, Neurologist 100% CBTMUSCULAR dySTROPHy Neurologist, Physician, Paediatrician 100% CBTMyASTHENIA gRAvIS Physician 100% CBTNARCOLEPSy Neurologist 100% CBTORgAN TRANSPlANT Appropriate multi disciplinary team 100% CBTOSTEOARTHRITIS Physician, Rheumatologist, gP 100% CBTOSTEOPOROSIS Physician, gynaecologist, gP 100% CBTPLEgIA; HEMI, PARA & QUAd Physician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, gP 100% CBTPOLyCySTIC OvARIAN SyNdROME gynaecologist 100% CBTPSORIASIS dermatologist 100% CBTRESTRICTIvE lUNg DISEASE Pulmonologist, Physician 100% CBTTRANSIENT ISCHAEMIC ATTACK / STROKE Physician, Neurologist 100% CBTTUBERCUlOSIS gP 100% CBTvAlvUlAR HEART DISEASE Physician, Cardiologist, Paediatrician 100% CBT

Benefit Option Change 2017

What makes CAMAF truly unique is the combination

of excellent cover, unmatched service and support and our real

commitment to ensuring that in both good times and bad,

we’re here for our members.

Evolving with you

2017 BENEFITS

What makes CAMAF truly unique is the combinationof excellent cover, unmatched service and support and our real

commitment to ensuring that in both good times and bad,we’re here for our members.

Evolving with you2017 BENEFITS

click here

to change your Benefit Option for 2017

ICD10 Codes 2017Benefit Practice type iCD 10 Codes iCD 10 DescriptiongP Consultation gP (14) Z00.0 general Medical Examination

Z00.1 Routine Child Health ExaminationZ00.8 Other general ExaminationsZ01.3 Examination Of Blood PressureZ01.4 gynaecological Examination (general)(Routine)Z10.8 Routine general Health Check-Up Of Other defined SubpopulationsZ12.4 Special Screening Examination For Neoplasm Of CervixZ12.5 Special Screening Examination For Neoplasm Of ProstateZ13.1 Special Screening Examination For diabetes MellitusZ13.6 Special Screening Examination For Cardiovascular disorders

Specialist Consultation Paediatrician (32) Z00.0 general Medical ExaminationZ00.1 Routine Child Health ExaminationZ00.8 Other general ExaminationsZ10.8 Routine general Health Check-Up Of Other defined Subpopulations

Specialist Consultation gynaecologist (16) Z00.0 general Medical ExaminationSpecialist Physician (18) Z00.8 Other general ExaminationsUrologist (46) Z01.3 Examination Of Blood Pressure

Z01.4 gynaecological Examination (general)(Routine)Z10.8 Routine general Health Check-Up Of Other defined SubpopulationsZ12.4 Special Screening Examination For Neoplasm Of CervixZ12.5 Special Screening Examination For Neoplasm Of ProstateZ13.1 Special Screening Examination For diabetes MellitusZ13.6 Special Screening Examination For Cardiovascular disorders

Melanoma Screening dermatologist (12) Z12.8 Special Screening Examination for Neoplasm of other sitesZ12.9 Special Screening Examination for Neoplasm, unspecifiedd22.0 Melanocytic naevi of lipd22.1 Melanocytic naevi of eyelid, including canthusd22.2 Melanocytic naevi of ear and external auricular canald22.3 Melanocytic naevi of other and unspecified parts of faced22.4 Melanocytic naevi of scalp and neckd22.5 Melanocytic naevi of trunkd22.6 Melanocytic naevi of upper limb, including shoulderd22.7 Melanocytic naevi of lower limb, including hipd22.9 Melanocytic naevi, unspecified

Contact UsCAMAFClient Relations* 0860 100 545E-mail [email protected] 0861 113 676Reception 0861 700 600Hospital Pre-authorisations 0860 100 544Hospital Pre-authorisations Fax 011 706 9946Hospital Pre-authorisations E-mail [email protected] Pre-authorisations Online www.camaf.co.zaWebsite www.camaf.co.zaMembership Fax 011 707 8735

Claims [email protected] post to PO Box 2964, Randburg, 2125

CAMAF liFEStylE PRogRAMMETelephone 0860 200 911E-mail [email protected]/onCology DiSEASE MAnAgEMEnt PRogRAMMETelephone 011 707 8461Fax 011 707 8466E-mail [email protected] SuPPoRt linETelephone 0860 100 544ChRoniC ConDition AuthoRiSAtionTelephone for:doctors and Pharmacists only 0800 200 300Members 0861 700 600 (Option 1 then option 3)Fax 011 707 8622E-mail [email protected] wEllnESS PRogRAMMETelephone 0860 100 544Fax 011 707 8747DiABEtES MAnAgEMEnt PRogRAMMETelephone 0861 700 600 (option 1 then option 3)Fax 011 707 8622E-mail [email protected] AnD hyPERliPiDEMiA PRogRAMMETelephone 0861 700 600 (Option 1 then option 3)Fax 011 707 8622E-mail [email protected]

liFESEnSE (hiv DiSEASE MAnAgEMEnt PRogRAMME)24 Hour Call Centre 0860 506 080E-mail [email protected] PRogRAMMETelephone 0860 100 544E-mail [email protected] 911Emergency Number 082 911Telephone 010 209 8911Fax 010 209 8405Namibia 09264 61 230 612PMB DtP AuthoRiSAtionFax 0861 700 600 (option 1 then option 3)E-mail [email protected] PRogRAMME

Telephone 0861 700 600 (Option 1 then option 3)

Fax 011 707 8622

E-mail [email protected]

StRESSlinE

Telephone 0861 700 600 (Option 1 then option 4)

Fax 011 707 8747


MultiPly (loyAlty PRogRAMME)

general Enquires 0861 886 600


Website www.momentum.co.za/multiply

intERnAtionAl tRAvEl inSuRAnCE DESK

Telephone0860 100 484 (RSA) or +27 (0)11 521 4000 (International)

PPn CAll CEntRE (network Choice, First Choice, Double Plus & Alliance members)

Telephone 0861 103 529 / 0861 101 477

Post Claims To PO Box 12450, Centrahil, 6006

Website www.ppn.co.za

glossary *More details available on the website www.camaf.co.za- for full explanations, consult the Registered Rules

ADult Refers to the member and dependants who are 22 or older at any time in the year of cover.

CBt CAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.

CDl Chronic disease List - the list of PMB’s includes 25 common chronic conditions called CdL’s. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (dSP’s).

CMl/ FoRMulARy Condition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is maintained by the Scheme and differs per Option. Reference pricing may still apply.

ChilD Refers to a dependant who is younger than an adult, as defined above.DiSPEnSing FEES Fee negotiated by the Scheme with Network pharmacies and added to SEP.

DSP The network of service providers contracted to provide healthcare services to members, eg. Independent Clinical Oncology Network (ICON), vitalaire for Oxygen, CPAP & Insulin pumps, HIv programme (LifeSense), PPN for optical benefits, Pharmacy networks for all chronic medications and Netcare hospital group for Network Choice hospital admissions.

DtP

The Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of diagnosis Treatment Pairs (dTP’s). A dTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 270 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (dSP’s).

iCD 10 CoDEStands for International Classification of diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. j03.9 is an ICd-10 code for acute tonsillitis (unspecified) and g40.9 denotes epilepsy (unspecified). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be paid from the correct benefit.

MEDiCAl SAvingS ACCount

A savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for: • top up on cost of service charged by a doctor • extension when an overall benefit has been exceeded • exclusion from benefits • payment of day to day claims on Essential Plus option

MEtABoliC SCREEning Newborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.

MMAP Maximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication.

nEgotiAtED RAtE This is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.

PMB

Prescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency medical condition • A limited set of 270 medical conditions (defined in dTP’s) • 25 chronic conditions defined in the CdL • These costs may not be paid from the member’s savings benefit and cost saving measures can be used by way of utilising dSP’s, Reference Pricing and Formularies.

PRE-AuthoRiSAtion A member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the Scheme as soon as possible after the event.

PRotoCol Means a set of guidelines in relation to diagnostic testing and management of specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines.

RiSK ContRiButionS Those funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.

RP Reference Pricing is the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated that a co-payment will apply. This includes MMAP.

SAlARy Total cost to company prior to deductions.

SChEME RAtE The maximum rate paid by the scheme to providers of healthcare services, based on SAMA (Private) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.

SEP Single Exit Price - nationally applied pricing for medication as determined by the department of Health and the pharmaceutical manufacturers.tto “To Take Out” - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply.

Evolving with you - CAMAF Medical · PDF fileAbout us The Chartered Accountants Medical Aid...

Documents

Transcript of Evolving with you - CAMAF Medical · PDF fileAbout us The Chartered Accountants Medical Aid...