CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd

CompCare Wellness Medical Scheme / Information and Benefit Guide 2017

/ WELLNESS / INNOVATION / INTEGRITY / DETERMINED / PERFORMANCE / MOTIVATED / INSPIRED / VICTORY / ACTIVE /

/ DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION / INTELLIGENT /

Introducing the “new look” CompCare Wellness Medical Scheme

Mumed OPTION

CompCare Awards and AccoladesThree CompCare options listed among 10 best value medical scheme options in 2015 – GTC Medical Aid Survey, 2016Healthiest Open Medical Scheme – GTC Medical Aid Survey, 2016Best Open Medical Scheme – BHF Titanium Awards, 2015 ED

NetcareYou’re in safe hands

Dis-ChemPharmacists who care

Efficiency Discounted Option

No matter whether you are a world-class athlete, a race car driver or someone who wants to realise your dreams, being a winner means that you need to achieve your optimum health at all times.

Your CompCare Wellness Medical Scheme option will support you in reaching many a health and wellness goal and should you not be at your peak, be there in the times when you need us most!

ACHIEVE YOUR OPTIMAL HEALTH WITH COMPCARE WELLNESS MEDICAL SCHEME

CompCare Wellness Medical Scheme was shown to be the healthiest medical scheme in South Africa based on affordability and benefits offered.*

As an innovative forward-thinking scheme, we deliver you best practice health and wellness solutions, best of breed benefits and quick and easy communication tools.

The Universal mobile App allows you access to your medical scheme information anywhere any time.

We consistently deliver lower than industry average contribution increases for our members.

With us you can rest assured that you will always stay at the centre of everything we do!We won a Titanium Award for Service Excellence awarded by the Board of Healthcare Funders (“BHF”).

*GTC Medical Aid Survey, 2016

Mumed ED / CompCare / 2017

Primary Care Benefits

With the Mumed ED option you and your family have access to five types of care:

Promotive – Health checks, disease management programme, healthy eating plans, exercise prescriptions, quit smoking programme and emotional wellness support.

Preventative – Immunisations, pap smears, PSA tests, mammograms and optometric checks.

Curative – Unlimited hospitalisation, comprehensive day-to-day benefits, GP visits, unlimited basic dental and an unlimited oncology programme.

Rehabilitative – Step-down facilities, post-operative benefits and home care.

Supportive/Palliative – Emotional wellness support, disease management programme, HIV management programme, Hospice and home care.

Because our focus is on preventing illness and promoting health as well as our primary healthcare approach ensures accessibility for all members at all times, independent of the availability of day-to-day benefits.

Families can count on receiving quality care from the most appropriate healthcare professionals at all times.

MUMED EFFICIENCY DISCOUNTED (ED) OPTION – A ROADMAP

Wellness Benefits

The Mumed ED option includes the following wellness benefits:

Pillar 1: New-born to adult benefits

Contraception, baby bag, childhood immunisation, school readiness assessments, career guidance (psychometric testing), pap smear, mammogram, tetanus vaccine, 360 health check (blood pressure, blood sugar, BMI, waist circumference, cholesterol), flu shot, malaria prophylaxis, cervical cancer vaccine, and many more.

Pillar 2: Fitness assessment and prescription exercise

Access to a biokineticist for exercise prescription at an accredited fitness facility.

Pillar 3: Nutritional assessment and healthy eating plan

Access to a dietician and a free weight control and healthy eating programme.

Pillar 4: Emotional wellness benefit

Access to unlimited telephone counselling and 3 face-to-face sessions with registered psychologists, counsellors and social workers.

The above wellness benefits are paid from risk and not from your Annual Flexi Benefit.

The Mumed ED option is a traditional option that offers above average cover, with unlimited hospital cover, within the Netcare Group of private hospitals. The plan offers day-to-day benefits consisting of flexible risk cover. Additional cover for specified services are available once the flexi risk benefit is exhausted.

• Annual Flexi Benefit (AFB)DAY-TO-DAY BENEFITS ARE SUBJECT TO:

• Wellness and Preventative Benefits• Unlimited GP visits Conservative Dentistry (after limits reached)• Ambulance Services Netcare911• Surgical and Medical Appliances

BENEFITS NOT SUBJECT TO AFB

•Unlimited cover for in-hospital and hospital-related servicesHOSPITAL BENEFIT (NETCARE HOSPITALS ONLY)

MumedED

Mumed ED / CompCare / 2017

Hospitalisation

Members have full access to all Netcare Private Hospitals in South Africa. All hospital accounts are paid in full at a rate agreed between the Scheme and the Hospital Group.

Voluntary, non-emergency admission to a non-Netcare facility will attract a co-payment of 30% with a minimum of R5 000.

In the case of elective admissions, authorisation must be obtained at least 48 hours before a beneficiary is admitted to a hospital or day clinic, failing which a co-payment of R2 000 per admission will apply. Late authorisations will require a R1 000 co-payment.

In the event of a medical emergency the scheme must be notified within one working day following the admission, failing which a co-payment of R500 per admission will apply.

CompCare Pre-authorisation / 0860 111 090

Co-payments are payable on specified elective procedures (excluding PMB’s*) done in a hospital or a day facility. For the co-payment schedule, please refer to www.compcare.co.za.

*PMB = Prescribed Minimum Benefit as defined in the Medical Schemes Act No 131 of 1998.

For the co-payment schedule, please refer to www.compcare.co.za.

Hospital related accounts

Unless otherwise indicated in-hospital related benefits are unlimited and accounts are paid at 100% of the scheme rate. These include but are not limited to:• General Practitioner visits• Radiology• Pathology• Surgical procedures• Blood transfusions• Auxiliary services (i.e. physiotherapy)• Sports injuries

Specialist accounts with the exclusion of dental accounts relating to hospital admissions are unlimited and paid at 100% of the scheme rate.

While in hospital medicine is unlimited, whilst medicine prescribed on discharge (Medicine TTO) is limited to a supply of seven days. Non-PMB medicine is subject to the reference pricing.

Biological agents and specialised medicines are limited to R124 000 per family. These medicines can only be obtained if pre-authorised.

Surgical Prostheses (e.g. artificial joints, stents, artificial limbs) and electronic/nuclear devices (e.g. pacemaker, defibrillators, nerve stimulators and cochlear implants) are limited to an overall limit of R36 750 per family. Sub-limits per sub-category apply. Sub-limits can be viewed on the CompCare website or obtained from the CompCare Call Centre.

Specialised radiology includes MRI, CT scans and high resolution PET scans and is limited to R22 000 per family per annum. Pre-authorisation is required for all MRI and CT Scans. High resolution CT Scans/PET Scans are subject to special medical motivation and also requires pre-authorisation. There is no benefit for unauthorised scans, except for PMBs. No benefits are available for screening or investigative purposes.

Maternity benefits

Confinements are limited to two days in hospital for a normal birth and three days in hospital for non-elective caesarean sections. Ultrasound pregnancy scans are limited to two 2D scans.

Mothers to be are encouraged to register on the maternity programme and obtain pre-authorisation for the confinement.

CompCare Pre-authorisation / 0860 111 090

Mental health benefits

Psychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health institution.

Non-Psychiatric hospital admissions are limited to R2 000 per family.

Alcoholism, drug dependence and narcotism hospitalisations are only authorised in the case of PMB conditions.

Pre-authorisation is required and protocols apply.

Hospitalisation relating to the following conditions and procedures are covered in full for PMB conditions only:

• Organ and tissue transplants• Renal dialysis• Plasmapheresis

Pre-authorisation is required and protocols apply.

The following alternatives to hospitalisation are available subject to pre-authorisation and protocols and unlimited unless otherwise specified:

• Step-down nursing facilities, hospice and rehabilitation• Terminal care (Imminent death, regardless of diagnosis)• Out-of-hospital surgical procedures• Oncology, including chemotherapy and radiotherapy (See limit on

biological agents and specialised medicines) • Wound care in lieu of hospitalisation• Excimer Laser Refractive Surgery limited to the day-to-day optical

limit

IN-HOSPITAL BENEFITS

Mumed ED / CompCare / 2017

Annual Flexi Benefit (AFB)

We pay your day-to-day medical expenses from the available funds in your AFB.The AFB is a risk benefit.

AFB Values for 2017

P A C

AFB R5 376 R3 372 R1 338

The value of the AFB is equal to up to 18% of annual contributions.PMB related benefits will be paid for from your AFB risk benefit.

The AFB will be pro-rated if you join during the course of the year.

Additional CoverWhen you run out of AFB, we will pay for specified healthcare expenses from risk. These include:

• GP visits (balance of consultations only)• Basic dentistry

The Mumed ED option provides cover for 32 chronic conditions. These include 26 conditions from the Chronic Disease List (CDL) as published in the Medical Scheme Act and 6 chronic conditions not listed as CDLs.

For a list of chronic conditions covered in the Mumed ED option, please refer to www.compcare.co.za.

CDL and Non-CDL chronic conditions are subject to the AFB. Once the benefit is depleted, CDL medicines are unlimited.

Members must obtain their chronic medication from a Dischem pharmacy (including Dischem Courier Pharmacy (DSP). A 25% co-payment will be payable upon voluntary use of the non- DSP Pharmacy

Medicine benefits for CDL chronic conditions (PMBs) are unlimited and initially paid from the member’s available AFB with no levy or co-payment if the medicine forms part of the scheme’s formulary and the price of the medicine is equal or less than the reference price for the product. Thereafter medicines are unlimited.

Non-CDL chronic medicines are paid from the member’s available AFB.

Members are required to register for all CDL and non-CDL applicable covered chronic conditions.

Prior to registration on the chronic programme, only the first prescription will be paid from the acute medicine limit. Formularies and reference pricing applies. A 25% co-payment is payable for the voluntary use of non-formulary medicine.

CompCare Chronic Registrations / 0860 111 900

CHRONIC CONDITIONS

DAY-TO-DAY BENEFITS

All benefits are paid at 100% of the scheme rate unless otherwise specified.

Benefits paid from available AFB where no sub-limits are

applicable

Sub-limits while AFB funds are available

GP Consultations, procedures and materials

M: 6 visits;M+1: 8 visits:

M+2: 10 visits:M+3+: 11 visits

Specialist Consultations, procedures and materials

Paid at 100% of the scheme rate

A referral from a GP is required before seeking treatment from a specialist except for services provided by an ophthalmologist, gynaecologist, oncologist or urologist (for beneficiaries over the age of 40) and a paediatrician in respect of children under the age of 2 years or where multiple visits to a specialist are authorisedAcute medicines Prescription medicines - Schedule 3 and higher

A 25% co-payment is applicable to non-generic products. Reference Pricing applies to medicines where a generic product is available and might result in a co-payment

Over the counter medicine (OTC) and homeopathic medicineR160 per event, R530 per

beneficiary per annum and R950 per family per annum

Basic radiology Including black and white X-rays and ultrasound

Specialised radiology MRI, CT, High resolution CT and PET scans

Combined in-and-out of hospital benefit, limited to R22 000 from in-hospital

benefit

Pathology Subject to AFB, combined

in-and-out of hospital benefit, limited to R27 500 per family

DentistryConservative and restorativeSpecialised dentistry Dentures, crowns, bridgework, metal fillings and inlays, orthodontics, prosthodontics, periodontics, Osseo integrated implants including the cost of the appliances and prosthesis, maxillofacial and oral surgery

Sub-limit of R1 850 per beneficiary

OptometryConsultations

One test per beneficiary every second year

OptometryLenses, contact lenses and disposable lenses

R1 450 per beneficiary and R4 125 per family every second

year

OptometryFrames

R730 per beneficiary every second year, included in lenses

limit Auxiliary services Including audiologist (to be recommended by a medical practitioner), chiropractors, Dieticians, homeopaths (Consultations), Naturopaths (Consultations), Speech and Occupational therapists, Chiropody/ Podiatry, Social workers, Physiotherapy and Biokineticists

R1 800 per beneficiary and R2 850 per family

Mental Health - Clinical psychologists R1 500 per familyMental Health - Psychiatry R3 800 per family

Oxygen-home ventilation

Private nursing homes Limited to 60 days per family

Ante-natal classes12 ante-natal classes, limited to

R680 per pregnancy

DAY-TO-DAY BENEFITS SUBJECT TO AFB

Emergencies

Ambulance services - Emergency roadside assistance and ambulance transportation.

NETCARE: 082 911

Hospital emergency room / Casualty emergency visits not requiring admission are paid from and limited to the member’s AFB.

Hospital emergency room / Casualty emergency visits resulting in a hospital admission will be paid from the in-hospital benefit.

Hospital emergency room / Casualty emergency visits as a result of physical injury caused by an external force will be paid in full.

Child emergency benefit - If the AFB is depleted members will have access to one additional visit to an emergency facility per child younger than 6 years per annum. Limited to R1 000 per event.

Surgical and medical appliances

Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators are paid from risk and are limited to R9 975 per family. Sub-limits per category apply. Sub-limits can be viewed on the CompCare website or obtained from the CompCare Call Centre.

Psychosocial counselling benefit

Unlimited telephonic counselling sessions with a psychologist or social worker with the option of referral for one-on-one sessions with qualified psychologists or social workers to a maximum of 3 sessions per beneficiary per annum.

Benefit relates to psychosocial counselling related to substance abuse, emotional stress, major life events e.g. birth, accidents and death, separation and loss, health care concerns, family or personal relationship issues, concerns about eldercare, childcare, parenting issues, family violence, harassment, work related stress, balancing work and family, etc.

Services provided by DSP Network of psychologists and social workers.

CompCare Care Counsellors / 0800 390 003

DAY-TO-DAY BENEFITS PAID FROM RISK

All wellness and preventative benefits are paid from risk.

Preventative benefits

Wellness Checks• One GP wellness consultation per beneficiary per annum.• Blood pressure, blood sugar, cholesterol, BMI and waist circumference

– one measurement per beneficiary over the age of 18 years, limited to R175 per event.

• Mammograms - one test per female beneficiary over the age of 35 every second year.

• Pap smears - one test per female over the age of 18 per annum.• PSA (Prostate Specific Antigen) - one test per male beneficiary over

the age of 40 per annum.• Dental - one check-up per beneficiary per annum.• Glaucoma test - one test per beneficiary per annum.• Baby wellness visits - two visits per annum for children between 4

weeks and 18 months.• Hearing and eye tests - one hearing and eye test for pre-school

children aged 5 to 6 years.• School Readiness Assessment (examination for admission to

educational institution (only tariff codes 86211 and 86290 qualify).• Career guidance (only tariff code 86211 and 86290 qualify).

Vaccinations and immunisations• Flu vaccinations - one dose per beneficiary per annum.• HPV (cervical cancer) vaccine - one course (3 doses per registered

schedule) per female beneficiary between ages 12 and 18 years.• Adult pneumococcal vaccine (pneumonia) as required.• Childhood pneumococcal vaccine as required.• Tetanus vaccine - one injection when required.• Childhood immunisations as recommended by the Department of

Health up to 12 years.

Healthy lifestyle benefits

• “Quit Smoking” programme limited to R3 000 per beneficiary once in a lifetime. Cost of programmes will be refunded to a member after the cotinine test to prove that member has quit smoking.

• Fitness assessment and exercise prescription – members have access to the Universal Network of biokineticists for an annual fitness assessment, exercise prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply.

• Fitness assessment for pregnant women – members have access to one fitness assessment per pregnancy. Pre-authorisation is required and protocols apply.

• Nutritional assessment and healthy eating plan – members have access to the Universal Network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply.

• Nutritional assessment for pregnant women - once per pregnancy.

Other preventative benefits

• Oral contraceptives – limited to R120 per beneficiary per month. Formulary and Reference Pricing applies.

• Malaria Prophylaxis (prevention medicine) as required.

WELLNESS AND PREVENTATIVE BENEFITS

Mumed ED / CompCare / 2017

COMPCARE WELLNESS MEDICAL SCHEME

CONTACT USCompCare Wellness Medical SchemeUniversal Place, 19 Tambach Road,Sunninghill Park, SandtonPO Box 1411, Rivonia, 2128

Tel: 0861 222 777 / Fax: 0866 450 991E-mail: correspondence@universal.co.zaWeb: www.compcare.co.za

Contact details for complaints escalated to the Council for Medical SchemesTel: 0861 123 267E-mail: complaints@medicalschemes.comWeb: www.medicalschemes.com

GLOSSARYA – Adult Dependant / AFB – Annual Flexi Benefit C – Child Dependant / CDL – Chronic Disease ListDSP – Designated Service ProviderOTC – Over the Counter MedicinePMB – Prescribed Minimum Benefits TTO – To Take Out (Medicine taken on discharge from hospital)

This brochure is a summary of the benefits of CompCare Wellness Medical Scheme. All information relating to the 2017 CompCare Wellness Medical Scheme benefits and contributions are subject to formal approval by the Council for Medical Schemes. On joining the Scheme, all members will receive a detailed member brochure, as approved. The final registered Rules of the Scheme will apply.

CompCare Wellness Medical Schemes is administered by Universal Healthcare Administrators (Pty) Ltd.

HOW WE HELP YOU TO ACHIEVE YOUR OPTIMAL HEALTH

1We are there for you in all healthcare aspects. Our focus is on preventing illness and promoting health and therefore each and every one of our options include promotive, preventative, curative, rehabilitative and supportive benefits.

2For peace of mind, we look at families holistically and acknowledge the life changes and needs of both parents and children. We therefore include appropriate care from appropriate healthcare professionals for the whole family.

3To perform at your peak we have included wellness benefits that support a healthy lifestyle. To assist you to reach your fitness goals, access to a biokineticist and an exercise prescription at a fitness facility. To reach your optimal weight access to a dietician, nutritional assessment and a healthy eating programme is available.

4Because your mental game is every bit as important as your physical game CompCare offers an emotional wellness benefit that provides you with unlimited telephone counselling and three face-to-face sessions with registered psychologists, counsellors and social workers.

5In the event of an accident or injury, CompCare will provide emergency assistance on the scene and transportation to a hospital, including airlifts.

6 CompCare covers all costs relating to sports injuries, including injuries when participating in Extreme Sports.

Contributions Effective From 1 January 2017Principal Member

Adult Dependant

Child Dependant

Monthly R2 054 R1 600 R572

Annual Benefit Amounts For 2017Principal Member

Adult Dependant

Child Dependant

Annual Flexi Benefit R5 376 R3 372 R1 338

* A child dependant is a dependant who is under the age of 21 years or a full time student up to the age of 27 years. An adult dependant is a dependant who is 21 years or older. The above rates are only applicable to the main member and a maximum of three child dependants.