Resolution Health Medical Scheme Membership Guidelines

1

2

structures that are well suited to your unique healthcare requirements.

Our dedication to your overall health and wellbeing is further complemented by Resolution Health’s enhanced partnership with Zurreal and you will continue to enjoy the exceptional benefits offered by the Zurreal loyalty and lifestyle programme at no additional charge. You also have the option of upgrading to the intermediate Zurreal Gold or extended Zurreal Platinum programme to unlock an astounding variety of additional lifestyle benefits that will further assist you to fully embrace life.

On behalf of the Scheme, I would like to once again thank you for choosing Resolution Health as your healthcare partner and we look forward to continue taking care of you and your loved ones through the provision of quality solutions.

Yours in health and wellness,

Mark ArnoldPrincipal OfficerResolution Health Medical Scheme

Dear member,On behalf of the Scheme, I would like to extend our sincere appreciation for your continued support and the integral role that you have played in further establishing Resolution Health as a market leader within the healthcare industry.

As a Resolution Health member, you can expect to enjoy superior benefits at affordable premiums and we look forward to taking care of your unique healthcare needs into 2014 and beyond.

As one of South Africa’s top 10 largest open medical schemes, you can rest assured that you belong to one of the industry’s most sustainable, innovative and forward-thinking medical schemes that always has your best interests at heart.

Our 2014 cover options offer a range of healthcare solutions that are tailor-made to meet the unique and varied expectations of the full consumer spectrum with each benefit structure specifically designed to ensure that you have appropriate medical scheme cover and are protected from inappropriate cross-subsidisation.

In summary, our six options include a mix of entry-level and hospital cover, as well as more comprehensive benefit

Zurreal is not part of the Resolution Health Medical Scheme. All Zurreal offerings are separate products sold (where relevant) and administered by Agility Channel

(Pty) Ltd, registration number 2004/003709/07.

3

Contents

This handbook has been designed to provide you with important information about your benefits and it is essential that you familiarise yourself with its contents.

Your needs and healthcare option 3 Your ideal Resolution Health option 3Membership details 5Termination of membership 6Monthly membership contributions 7Claims procedure 7Benefits 7Emergency services 8Prescribed Minimum Benefits (PMB) 8Dental benefits 9Optical benefits 9Maternity programme 10Health assist 10Chronic medication: Chronic diseases and additional chronic conditions 10 Pharmacy preferred provider network 11Oncology benefits 11HIV 11Exclusions (services or events not covered by the Scheme) 11Hospitalisation and authorisation 13Co-payments 13Other insured benefits 14External medical appliance sub-limits 15Childhood immunisations 16Late joiner penalties 16Definitions 17

*Register for e-statements now online to receive your statements via e-mail* This Member Guide does not replace the Scheme’s Rules.

The registered Rules are legally binding and will always take precedence.

Millennium

The Millennium option combines the flexibility of a medical savings plan with an Above Threshold Benefit (ATB) when your day-to-day expenses are particularly high. This option allows for unused savings to be carried over annually to the next year and includes comprehensive in-hospital and chronic cover.

• Contracted specialists paid up to 150% of Scheme rate in and out of hospital.

• Cover for 36 chronic conditions.• Generous savings account for day-to-day expenses.• Access to comprehensive Preventative Care Programme,

including oral contraceptive.• FREE access to Zurreal, an exceptional loyalty and

lifestyle programme that provides more benefits, more often.

Classic

The Classic option is traditional in design, and provides balanced in-hospital and day-to-day benefits at affordable premiums. This option encompasses exceptional benefits for the little ones, making it ideal for young families who place a premium on choice and affordability.

• Hospitalisation at any hospital.• Contracted specialist fees paid up to 150% of Scheme

rate in and out of hospital.• Cover for 31 chronic conditions.• Extended maternity benefits including 4 2D scans and

postnatal maternity visits.• 2 Additional paediatrician visits per beneficiary less than

2 years of age and 2 additional GP visits per beneficiary between the ages of 2 and 12 years.

• Reduced co-payments on selected child-related procedures.

• FREE access to Zurreal, an exceptional loyalty and lifestyle programme that provides more benefits, more often.

1. Your needs and ideal healthcare optionResolution Health has simplified the process of choosing your ideal healthcare cover by providing easy to understand benefit structures. Each of our six options provides cover that is specifically designed to meet the needs of individuals, families and employers both through benefit design and affordability.

When choosing Resolution Health as your healthcare partner, our benefit rich options translate into true value for money:

• All Resolution Health members have access to exceptional loyalty and lifestyle benefits offered by the Zurreal programme at no additional charge.

• All options include access to private hospitals.• Specialised radiology is included across all options.• All Resolution Health options include a comprehensive

chronic medication list, with automatic authorisation for chronic medication.

• All options include a 7-day medication benefit on discharge from hospital.

• Generous preventative care benefits, including oral contraceptives on most options.

• Cervical cancer vaccines on the Supreme option.

Note:The outlines of the different plans below need to be read in conjunction with the detailed benefit schedules, as well as all other Scheme rules, protocols and policies.

Should you wish to change your benefit option for 2014, a written application must be submitted to the Principal Officer by no later than 07 December 2013.

Your ideal Resolution Health option

Supreme

The Supreme option provides comprehensive in-hospital benefits, generous day-to-day benefits and superior cover for 53 chronic conditions. This option is ideal for those individuals and families who require extensive cover and place a premium on complete peace of healthcare mind.

• Contracted specialists paid up to 220% of Scheme rate in and out of hospital.

• Generous casualty benefit for emergencies.• Excellent day-to-day benefits.• Unlimited GP benefits.• Trauma counselling benefit.• Limited procedure co-payments.• Access to Preventative Care Programme including the

cervical cancer vaccine and oral contraceptives.• FREE access to Zurreal, an exceptional loyalty and


5

Progressive Flex

Progressive Flex is a balanced option which is ideally suited to young couples or healthy families. Progressive Flex provides sufficient medical scheme cover for day-to-day expenses as well as hospitalisation through a contracted network.

• Access to Preventative Care Programme, including oral contraceptive.

• Flexi Benefit for use on listed sub-benefits (member defines allocation).

• Separate benefit for acute, as well as schedule 0 - 2 (over the counter) medicine.

• Casualty benefits for emergencies.• FREE access to Zurreal, an exceptional loyalty and


Hospital

The Hospital option is one of the most balanced options in its category and is ideally suited for young and healthy individuals who are able to manage their own day-to-day healthcare requirements.

• Hospitalisation at any hospital.• Contracted providers paid at 100% of Scheme rate. • Oncology benefit at ICON network.• Chronic medication benefit for 28 conditions.• FREE access to Zurreal, an exceptional loyalty and


Foundation

The Foundation option is an ideal entry-level healthcare plan for basic day-to-day cover and in-hospital benefits, perfectly suited to lower-income employees of employer groups.

• Hospital cover at DSP hospital networks (Scheme protocols apply).

• Maternity benefit, including 9 antenatal visits at network providers.

• Unlimited GP access at network DSP providers.• Acute medication at DSP providers (basic formulary and

protocols apply).• FREE access to Zurreal, an exceptional loyalty and


6

2. Membership detailsChange of personal details

To ensure that you receive important Scheme information and enjoy prompt claims management, it is of utmost importance that the Scheme has your most recent contact details, including:

• E-mail address.• Cell phone number for SMS notifications.• Claims refund banking details.• Contribution banking details.

You can update your details by logging onto our website at www.resomed.co.za to download the necessary forms.

Note:The Scheme is not responsible if a member’s rights are prejudiced or forfeited, should we not have your updated details.

Statements will be sent electronically to all members with email addresses.

Confidentiality

Resolution Health has the highest regard for upholding and maintaining the confidentiality of members and their dependants at all times. In line with the Scheme’s commitment to ensure that its members receive appropriate and necessary medical services, while reducing inappropriate care and waste of medical resources, all members recognise and accept that Resolution Health and any hospital concerned may share any member information deemed necessary to relevant parties appointed by the Scheme.

Dependants

A dependant is defined as a person who is an immediate family member and / or financially dependent on the principal member. This person should not receive remuneration of more than the maximum social pension per month or belong to another medical scheme.

The dependants of a member who are registered with the Scheme at the time of the member’s death, may retain their membership without any new restrictions, limitations or waiting periods applied.

Dependants who become orphaned (according to the definition in the Scheme’s rules) as a result of a member’s death, will remain a member until they become a member of the Scheme in their own right, or are accepted onto any other registered medical scheme, provided the monthly contributions are paid.

To add a dependant, visit www.resomed.co.za and download a Registration of Additional Dependant form. Please email the completed forms to [email protected] or fax to 086 513 1438.

Registration of dependants / spouse

Members may apply for the registration of dependants on application for membership, or any time thereafter as they become dependants of the main member.

Should a member wish to apply for the membership of additional dependant(s) over the age of 21 years, proof of full-time student status from a registered institution must be submitted to confirm the dependant’s financial dependency on the main member. The following proof should accompany the Registration of Dependant application form which can be downloaded from www.resomed.co.za:

• Proof of full-time student status from a registered institution.

• Should a member wish to apply for membership of additional dependant(s) over the age of 21 years, an affidavit must be submitted to confirm that the dependant is financially dependent on the main member.

• Handicapped children: Physician report to confirm disability.

Note: The Scheme allows a dependant who studies full-time to remain on the Scheme as a child dependant until the age of 25 years. Please ensure that proof of dependency, i.e. a student certificate, is submitted, along with the application form, to [email protected] to maintain their status. If proof is not received on an annual basis, the child dependant will be defaulted to adult dependant status. Membership status will be backdated upon receipt of proof of student status.

New-borns / adoptions

The arrival of a new baby is always an exciting event and, as a Resolution Health member, you can rest assured that their healthcare expenses will be covered in line with your selected option’s benefit structure. Please note that the new-born or newly adopted baby must be registered with the Scheme within 30 days of birth or adoption.

Contributions for the newly registered dependant are due from the first day of the month following the birth or adoption. Benefits will be calculated from the date of birth or adoption, provided the necessary documentation is received, together with the application for registration within 30 days of birth or adoption. Kindly fax a copy of the birth certificate or registration to 086 513 1438 or send an e-mail to [email protected].

Note: If a new-born baby or newly adopted dependant is not registered within 30 days of birth or adoption, benefits will only be available from the date of registration and not retrospectively from the date of birth or adoption.

7

Deregistration of dependants

To ensure efficient service, it is of utmost importance that you keep your member information up to date.

Kindly let us know, within one calendar month, of any event that changes the status of a dependant which may result in their membership becoming invalid. When such dependant no longer qualifies for membership, they will be deregistered and will no longer be entitled to any benefits.

Visit www.resomed.co.za to download a Deregistration of Dependants form. Please email the fully completed form to [email protected] or fax to 086 513 1438.

Eligibility

Membership is open to all individuals and groups and is subject to the rules, protocols and policies of the Scheme.

Membership cards

The Scheme routinely issues two membership cards per family and a single card for individual members. The membership card is used to identify you as a member of the Scheme and allows you to obtain services from medical service providers so long as your membership remains current.

Should you require additional cards, please submit a request by:

• Sending an email to [email protected].• Getting in touch with our Client Services department on

0861 796 6400.• Visiting www.resomed.co.za to download the necessary

form.

Note: It is illegal to use a membership card that does not belong to you. The unauthorised use of a membership card is considered a fraudulent claim on the Scheme’s membership privileges and will result in such membership being cancelled immediately.

3. Termination of membershipMembership may be terminated for the following reasons:

Abuse of privileges, false claims, misrepresentation and non-disclosure of factual information

The Scheme will terminate the membership, or exclude a member or dependant(s) from benefits, for any abuse of the benefits and privileges of the Scheme by presenting false claims, material misrepresentation or non-disclosure of information.

Failure to pay amounts due to the Scheme

Members who fail to pay all due amounts to the Scheme will have their membership terminated in terms of the rules of the Scheme.

Employer resignation from the Scheme

Members who belong to Resolution Health in terms of their conditions of employment, and whose employer elects to resign from the Scheme and does not join another scheme as an employer group, will not be members from that date, unless they elect to continue membership in their private capacity. The Scheme requires one calendar months’ notice period prior to termination.

Resignation from employment

Members who belong to Resolution Health in terms of their conditions of employment may not resign from the Scheme without written consent from their employer. On resignation, membership and benefits end as of the date of resignation, unless members elect to continue membership in their private capacity. Subject to Scheme rules.

Voluntary termination

Members who do not belong to Resolution Health in terms of their conditions of employment may terminate their membership by giving one calendar months’ written notice. Employers who wish to end their association with the Scheme may do so by giving one calendar months’ written notice.

Death

Membership is terminated on receipt of a death certificate.

8

4. Monthly membership contributionsMembership contributions are due monthly in advance and are payable no later than the 5th day of the month. Late payments will result in suspended benefits or cancellation of membership.

Should contributions not be paid by the 5th of each month, the Scheme will notify the member or employer via their selected preferred method of communication (email, SMS or post), that membership will be suspended should all debts not be paid by the 15th of the month.

Should the member or employer pay by debit order, and their premiums have not been brought up to date by the next payment run, the Scheme will process a double debit order to recover outstanding contributions.

Benefits will be reinstated when outstanding premiums are paid up to date, provided that membership has not been cancelled. If payments are not brought up to date, the member will not be entitled to any benefits from the date of default of payment. Any benefit already paid will be recovered by the Scheme. If outstanding contributions are not paid by the 15th of the subsequent month, membership will be cancelled.

Note: No refunds or portion of a member’s contribution will be paid where membership, or cover in respect of dependants, terminates during the course of a month.

5. Claims procedureShould your medical service provider not submit claims to the Scheme electronically, please submit a signed claim to [email protected] or send to:

Resolution Health Medical SchemePO Box 1075Fontainebleau2032

The following details are required before a claim will be accepted:

• Membership number.• Name of the option.• Member’s surname and details.• Surname, initials and other details of the patient.• The practice number, group practice number and

individual provider registration number of the service provider and, in the case of a group practice, the individual practice number of the specific service provider.

• Date when the service was rendered.• The nature and cost of services rendered, including

the supply of medicine to the member or registered dependant, with the name, quantity and dosage of the medicine. Include the net amount payable by the member for the prescribed medicine.

• The relevant diagnostic (ICD-10) and tariff codes relating to the service. Should these codes not appear on the account, they should be obtained from the service

provider prior to submission of the claim.• If the member has already paid the account, the original

receipt must be submitted with the claim.• Claims must reach the Scheme by no later than the last

day of the 4th month following the month in which the service was rendered. Accounts for treatment of injuries or expenses recovered from third parties must be supported by a statement detailing the circumstances in which the injury was sustained or the accident occurred.

Claims payments to service providers and members take place twice a month or at the Scheme’s discretion. The Scheme will supply the member with a detailed claims statement after every payment run. Should there be any irregularities on the account, the Scheme will state the reason for the error or why it was rejected. The member or service provider then has the opportunity to return the corrected claim within 60 days of such notice.

Note: To qualify for benefits, all claims must correspond with the claim requirements specified in the Scheme rules. It is important to confirm that a claim complies with all other benefit schedule stipulations, protocols and policies to be accepted for payment. Please refer to section 6.11 on page 11 for an overview of applicable Scheme exclusions.

6. BenefitsResolution Health provides a range of options that will suit your every healthcare need and lifestyle requirement. Members may change benefit options subject to the following:

• Option changes may only be made annually, effective 01 January.• A written application to change your benefit option must

reach the Principal Officer by no later than 7 December for the next year.

It is important that members familiarise themselves with the benefits included in their selected option, as well as the list of approved chronic conditions (section 6.7, page 10) and exclusions (section 6.11, page 11) to ensure they select the most appropriate option for the year.

The healthcare benefits per option are detailed in the option-specific benefit schedules that can be:

• Downloaded from the Resolution Health website at www.resomed.co.za.• Requested from our Client Services department on 0861 796 6400.

Note:All benefits are subject to the Scheme rules, protocols and policies in effect at the time, even if not explicitly stated in the benefit schedule, and cannot be read in isolation. In the event of any dispute, the Scheme rules, protocols and policies will prevail.

Some service providers charge rates above the benefit rate stipulated in the option benefit schedules and it is essential that members determine upfront what providers charge prior

to them incurring any expense. The Scheme will only fund tothe limit of the benefit rate specified in the benefit schedule, including for Prescribed Minimum Benefits (PMBs).

Note:Some service providers also charge members in addition for procedure codes or the unbundling of service tariffs not approved by the Scheme. Members are encouraged to obtain guidance from the Scheme’s Pre-Authorisation department on 0861 111 778 or [email protected] as they may also not be liable for these additional costs.

Members and their dependants are entitled to the benefits of their option during a calendar year. However, certain benefits cross over years, e.g. the frequency cycles of external medical appliances, orthodontics and optical benefits and cochlear implants (a lifetime benefit). Limits and sub-limits also apply to certain benefits, as specified in the benefit schedule.

Once benefits are depleted, only additional interventions that qualify as clinically proven PMBs will be funded according to Scheme protocols. All options cover PMBs, subject to the benefit schedule and Scheme protocols. Pre-authorisation and proof of PMB status are required to confirm PMB funding.

When joining the Scheme during the year, all benefits (except hospitalisation) and other risk benefits that have Rand limits, are pro-rated in proportion to the remaining period of membership for the year. Upon resignation, all benefits (except hospitalisation) and other risk benefits that have Rand limits are pro-rated in proportion to the period of membership prior to resigning.

6.1 Emergency services (0861 112 162)

Resolution Health, in partnership with Europ Assistance, offers access to 24-hour emergency medical assistance anywhere in South Africa. Should a member be unable to get to a hospital in the event of an emergency, appropriate transportation such as an ambulance, will be arranged. In addition to emergency transportation, the Medical Evacuation product also offers:

• Emergency telephonic medical advice.• Dispatch of ambulances and flights.• Arrangements for compassionate visits by a family

member.• Arrangements for the escorted return of minors after an

accident.• Repatriation to appropriate facility in area of residence

after an accident.• Referrals to doctors and other medical facilities.• The relaying of information to a family member or

acquaintance.• Telephonic trauma counselling.

6.2 Prescribed Minimum Benefits

Prescribed Minimum Benefits (PMBs) is a list of diseases or conditions listed in the Medical Schemes Act which schemes are required to fund. Included in this is the Chronic Disease List (CDL) of chronic conditions that also fall under the umbrella of PMBs.

In certain circumstances, the Scheme may only provide cover for members and their dependants in provincial hospitals or at the Scheme’s appointed private Designated Service Provider (DSP) facilities. All PMB conditions will be funded according to Scheme rules and protocols at the appropriate level of care. The list of PMB conditions and ICD-10 codes is available from the Council for Medical Schemes website on www.medicalschemes.com.

PMB conditions include approximately 95% of all medical conditions. PMBs are funded from existing benefits provided in the schedule first. Any additional funding for subsequent PMB conditions beyond benefits requires confirmation of the clinical condition and ICD-10 code, as for any PMB condition, including (for example):

• Doctor motivations.• Any supporting documents such as radiology and

pathology reports. • Any other documentation required by the Scheme to

confirm the ICD-10 code on accounts.

All PMBs are funded up to the benefit rates provided for in the benefit schedule, except in true verifiable emergencies which, by definition, require immediate treatment (without any delay) and are funded up to the maximum of the contracted DSP rate or 300% of the Scheme rate for non-contracted providers, only for as long as such condition prevents accessing a DSP.

The minimum level of medical cover for PMBs is that provided in the state or public sector. The Scheme has certain provisions which members must observe to ensure cover for PMB benefits, as specified in the benefit schedules. These may include:

• DSP hospital networks, medical practitioners, other professional providers, dialysis, oncology, pharmacy networks etc.

• Clinical confirmation of a PMB condition, as above.• Pharmaceutical formularies, including reference and

Generic Reference Pricing (GRP).

10

• Treatment and condition protocols and policies, including level of care protocols.

• Treatment algorithms for CDL and other PMB conditions.

Benefits will be restricted to PMB cover in the following circumstances:

• Where a member or their dependant(s), who could reasonably have obtained a service from a preferred provider, chooses to use another provider of their choice. The Scheme’s liability for the costs of obtaining such services will be restricted to the benefit rate provided in the benefit schedules.

• New members with waiting periods imposed upon joining the Scheme may or may not have cover for PMB conditions. Members should confirm this on their Terms of Acceptance letter.

• Where a PMB condition requires further treatment but annual benefits have been exhausted.

• Where benefits in the benefit schedule are limited to PMBs.

Note: Where specific benefits are limited to PMB conditions, members may be liable for a co-payment if services are obtained from a non-DSP facility or other provider.

6.3 Dental benefits

General

Dental benefits can be obtained from any provider, but will be funded according to Scheme-specific rates. Preferred providers are contracted to charge and deliver services according to the Scheme-specific rates. It is therefore advised that members use preferred providers to ensure no out-of-pocket co-payment expenses.

Co-payments may be applicable if members choose to use a non-preferred provider or services that are not covered in their specific benefit option. The Scheme benefits and protocols, as well as the list of preferred providers and dental rates, are available on www.resomed.co.za. Please familiarise yourself with the defined benefit before visiting your dentist.

Advanced dentistry always needs to be pre-authorised. Please refer to section 6.11 on page 11 for an overview of applicable Scheme exclusions.

Anxious patients

Many patients are anxious about dental treatment and mild sedation is required from time to time. Please note that hospitalisation and general anaesthesia are not covered where patients require anxiety control only.

Benefits are payable for sedation methods such as laughing gas or sedative medications. No pre-authorisation is required for laughing gas or sedative medications. Benefits for laughing gas and conscious sedation are not available on the Hospital option.

Conscious sedation (intravenous sedation) for surgical procedures require pre-authorisation and are subject to Scheme protocols.

General anaesthesia and hospitalisation

Hospitalisation for dentistry is not automatically covered and is subject to pre-authorisation. Members on the Hospital option are liable for procedure and service provider costs. Multiple hospital admissions on the Hospital option are not covered.

Hospitalisation for the removal of impacted teeth in adults is available on all Resolution Health options. General anaesthetic benefits are available for very young children (younger than 5 years of age) for extensive dental treatment (multiple extractions and fillings), subject to admission protocols.

Hospitalisation protocols

• Where an underlying medical condition creates a substantially increased risk of treatment in the dentist’s room and justifies admission, an authorisation may be granted. A medical report from a medical practitioner confirming the medical condition will be required.

• Multiple hospital admissions are not covered.• An X-ray or clinical report may be requested to process a

hospital pre-authorisation.• Hospitalisation for impacted teeth will only be authorised

for pathology or severe pain based on Scheme protocols and evidence.

• Soft tissue impactions will not be covered.• Hospitalisation is not covered where anxiety of dental

treatment is the reason for the admission.

6.4 Optical benefits

Optical benefits are subject to a 24-month benefit cycle and can be obtained from any provider, but will be funded according to the Scheme-specific optical rates and tariff structures to ensure no co-payments or rejected claims. Preferred providers are contracted to charge and deliver services according to Scheme-specific rates and it is therefore advisable to use preferred providers to facilitate ease of access and ensure no co-payments.

Co-payments may be applicable if members choose to use a non-preferred provider or enhancements which fall outside the option-specific entitlements.

Scheme benefits and protocols, as well as the list of preferred providers and optical rates, are available on the website on www.resomed.co.za. Please familiarise yourself with the defined benefit before visiting your optometrist.

6.5 Maternity programme

All expectant members have access to the maternity programme which includes baby care products, professional consultations, 2D scans, antenatal classes and postnatal midwife visits (option dependent).

Following confirmation of the pregnancy by a blood test, members can register for the maternity programme by sending an email to [email protected] or contacting the Pre-Authorisation call centre on 0861 111 778.

All plans cover two 2D ultrasound scans, except for the Classic option which covers four 2D scans per pregnancy.

6.7 Chronic medication: Chronic diseases and additional chronic conditions

After the 32nd week of pregnancy, members must call the Maternity Personal Care Coordinator to activate the baby care product voucher on the applicable option. The voucher can be redeemed at any preferred provider pharmacy. The baby care benefit is valid for 1 year from the date of activation.

6.6 Health Assist (Nurse Helpline 0861 112 162)

The Nurse Helpline provides advice 24-hours a day and includes:

• Emergency medical advice.• Appropriate first aid advice in case of emergency.• Assessing day-to-day symptoms.• Important health knowledge and counselling.• Drug database.• Poison information.• HIV / AIDS and cancer.• Addiction.• Trauma counselling.

CHRONIC DISEASES (ALL OPTIONS)

CLASSIC OPTIONADDITIONAL CHRONIC

CONDITIONS

MILLENNIUM OPTIONADDITIONAL CHRONIC

CONDITIONS

SUPREME OPTIONADDITIONAL CHRONIC

CONDITIONS• Addison’s Disease

• Asthma

• Benign Prostatic Hypertrophy

• Bipolar Affective Mood

Disorder

• Bronchiectasis

• Cardiac Dysrhythmia

(Arrhythmia)

• Cardiac Failure

• Cardiomyopathy

• Chronic Obstructive

Pulmonary Disease (COPD)

• Chronic Renal Disease

• Crohn’s Disease

• Diabetes Insipidus

• Diabetes Mellitus Type 1 & 2

• Epilepsy

• Glaucoma

• Haemophilia

• HIV

• Hormone Replacement

Therapy (HRT)

• Hyperlipidaemia

• Hypertension

• Hypothyroidism

• Ischaemic Heart Disease

(Coronary Artery Disease)

• Multiple Sclerosis

• Parkinson’s Disease

• Rheumatoid Arthritis

• Schizophrenia

• Systemic Lupus Erythematosis

• Ulcerative Colitis

• ADHD

• Allergic Rhinitis

• Eczema

• ADHD


• Arthritis

• Eczema

• Gastro-Oesophageal Reflux

Disease (GORD)

• Gout

• Major Depression

• ADHD


• Angina Pectoris

• Ankylosing Spondylitis

• Arthritis

• Cerebrovascular Accident

(Stroke)

• Cushing’s Syndrome

• Delusional Disorder

• Eczema

• Gastro-Oesophageal Reflux

Disease (GORD)

• Gout

• Hyperthyroidism

• Idiopathic

Thrombocytopenic Purpura

• Interstitial Fibrosis of the

Lung

• Major Depression

• Meniere’s Syndrome

• Motor Neuron Disease

• Myasthenia Gravis

• Osteoporosis

• Paget’s Disease

• Peripheral Vascular Disease

• Pituitary Adenoma

• Psoriasis

• Scleroderma

• Urinary Incontinence

12

How to register for chronic medication

To register a chronic condition, your doctor or pharmacy must phone our Pre-Authorisation department on 0861 111 778 with the required ICD-10 codes and relevant test results. This service is available from Monday to Friday, 07:30 – 16:30.

Note: All chronic conditions are managed according to disease management protocols and formularies, and medication with reference and Generic Reference Pricing (GRP).

6.8 Pharmacy preferred provider network

The list of Resolution Health recommended pharmacies is available on the Scheme website on www.resomed.co.za.

Any additional costs incurred at one of these recommended pharmacies may be due to:

• Reference pricing.• GRP.

6.9 Oncology benefits

The oncology benefit covers chemotherapy, radiotherapy, oncologist fees and blood tests within benefit limits, protocols and guidelines at benefit schedule rates. Other investigative work-ups are allocated to out-of-hospital benefits and thereafter PMBs according to Scheme protocols.

Benefits are based on the option-specific ICON Network protocols and pre-authorisation is required. A preferred provider network is in place for all options and all Scheme rules and protocols apply. Pre-authorisation requires the submission of a treatment plan by the oncologist to [email protected]

Note: Reference pricing and GRP are applicable for all oncology medication.

6.10 HIV

Resolution Health provides for out-patient care including consultations, blood tests, counselling and medication. Registration is required to access this benefit and can be obtained:

• Telephonically by calling 0861 111 778.• Via the HIV helpline at 082 584 0588.• Via email at [email protected].• Via fax on 086 556 3855.

Note: Hospitalisation for HIV positive members is only funded in a provincial facility if you are not registered and compliant on the HIV Management Programme. Thus, any admission to a private hospital under these circumstances will only be funded at provincial rates and members will be financially liable to the private hospital for any shortfall.

To avoid this, it is important that HIV positive members register with the HIV Management Programme.

6.11 Exclusions (services or events not covered by the Scheme)

With due regard to PMBs in either a public care system or at the facilities of one of the Scheme’s designated or preferred service providers, as contemplated in Regulation 8 of the Regulations promulgated in terms of the Act, or provided for in a benefit option, the Scheme’s liability is limited to the cost of medical services as defined in the Act and provided for in the rules of the Scheme and, further subject to the provisions of Rule 1.3 of Annexure B, expenses in connection with any of the following shall not be paid by the Scheme:

1. Compensation for pain and suffering, loss of income, funeral expenses or claims for damages.

2. Expenses incurred for recuperative or convalescent holidays.

3. Services not considered appropriate in terms of managed healthcare principles, or that are not lifesaving, life sustaining or life supporting. The Scheme reserves the right to determine such instances, in general or for specific instances at any time, at its discretion. The following conditions, procedures, treatments and apparatus will specifically be excluded:

3.1 Any breast reduction, augmentation or breast reconstruction unless related to diagnosed malignancy in the affected breast (subject to Scheme protocols). Prophylactic mastectomy only considered for BRCA mutations. Reconstruction following prophylactic mastectomy will not be funded.3.2 Gynaecomastia.3.3 Hyperhidrosis.3.4 Eximer laser and radial keratotomy.3.5 Phakic implants.3.6 Bariatric surgery and other treatments, services or charges for, or related to, obesity.3.7 Keloid and scar revision and any other cosmetic procedures and treatments.3.8 Dynamic spinal devices.3.9 CT or virtual colonoscopy.3.10 Change of sex operations and procedures.3.11 Growth hormone.3.12 Sleep and hypnosis therapy.3.13 Elective caesarean section (except Supreme option).3.14 Cancer treatment outside network protocols.3.15 Medicines not registered with or used outside their Medicines Control Council registration or proprietary preparations.3.16 Medication outside the formulary.3.17 Pre-hospital admissions.3.18 Nasal reconstruction.3.19 Bat-ears.3.20 Removal of skin blemishes.3.21 Liposuction.3.22 Face-lift and eyelid procedures.4. Exercise programmes.5. Kilometre charges and travelling expenses with the exception of ambulance services.6. Examinations and tests for the purpose of application for insurance policies, school camps, visas, employment, emigration or immigration, admission to schools or universities, medical court reports as well as fitness examinations and tests.

13

7. Charges for appointments not kept.8. Accommodation in convalescent, old age homes, frail care or similar institutions.9. Costs associated with vocational guidance, child guidance, marriage guidance, school therapy or attendance at remedial education schools or clinics.10. Purchase of:10.1 Applicators, toiletries, sunglasses and / or lenses for sunglasses and beauty preparations.10.2 Patented foods or medicines, special foods and nutritional supplements including baby foods.10.3 Remedies for the treatment of infertility.10.4 Tonics, slimming preparations, appetite suppressants and drugs as advertised to the public for the specific treatment of obesity, including all cost escalations and / or increases for any services accessioned by or in relation to obesity.10.5 Sunscreen and sun tanning lotions.10.6 Soaps and shampoos (medicinal or otherwise).10.7 Household and biochemical remedies, including complementary and alternative medications, which are not registered, prescribed or promoted by the medical profession with or without evidence to support benefit (Scheme protocols and assessment will apply).10.8 Cosmetic products (medicinal or otherwise).10.9 Anti-habit-forming products.10.10 Vitamins and multi-vitamins unless prescribed by a person legally entitled to prescribe and for a specific diagnosis registered and authorised by the Scheme.10.11 Remedies for body building purposes or exercise and sport-specific enhancers.10.12 Aphrodisiacs.10.13 Household bandages, cotton wool, dressings and similar aids.11. Infertility, sterility or artificial insemination of a person as defined in the Human Tissue Act, (Act 65 of 1983), as well as vaso-vasostomies (reversal of sterilisation procedures). Subject to PMBs.12. Diagnostic tests and examinations performed that do not result in confirmation of the diagnosis of a PMB condition, unless such condition qualifies as a bona fide emergency medical condition. Diagnostic tests will only be funded up to, and inclusive of, the minimum tests required to exclude a PMB condition.13. Repair of hearing aid and medical apparatus.14. Experimental, unproven or unregistered treatment or practices.15. Donor costs in respect of an organ transplant will not be covered by the Scheme unless the recipient is a member of the Scheme for a PMB related transplant.16. Interest and legal costs on outstanding accounts.17. Oral contraception on Foundation and Hospital options.18. Dental surgery exclusions:18.1 Bone augmentations.18.2 Sinus lifts.18.3 Bone and tissue regeneration.18.4 Gingivectomies.18.5 Surgical procedures associated with dental implantology.18.6 Oral hygiene instructions.

18.7 Professionally applied topical fluoride in adults.18.8 Nutritional and tobacco counselling.18.9 Root canal treatment on third molars (wisdom teeth) and primary teeth.18.10 Ozone therapy.18.11 Soft base to new dentures.18.12 Apisectomies in-hospital.19. Subject to PMBs, the Hospital and Progressive Flex options have the following additional condition and procedure exclusions:19.1 Joint replacements.19.2 Spinal surgery and conservative treatment including rhizotomies.19.3 Admissions for skin lesions.19.4 Cochlear implants.19.5 Implanted neurological devices including, but not limited to, nerve stimulators, processors and procedures.19.6 Neonatal Respiratory Syncytial Virus prophylaxis.20. Subject to PMBs, the Foundation option has the following additional condition and procedure exclusions:20.1 Dental hospitalisation.20.2 Joint replacements and rotator cuff surgery.20.3 Back and neck surgery and conservative treatment including rhizotomies.20.4 Gastro-oesophageal reflux and hiatal hernia surgery and treatment.20.5 Functional nasal surgery.20.6 External abdominal hernias.20.7 Bunion and ingrown toenail surgery.20.8 Entropion, ectropion, eyelid, pterygium and strabismus surgery.20.9 Corneal cross-linking.20.10 Polysomnogram.20.11 Admissions for skin lesions.20.12 Cochlear implants.20.13 Implanted neurological devices, processors and procedures.20.14 Laparoscopies.20.15 Hyperbaric oxygen.20.16 Neonatal Respiratory Syncytial Virus prophylaxis.20.17 The costs related to any complication or review of these conditions and treatments.20.18 No other benefits for any other confirmed conditions not listed in the Council for Medical Schemes’ PMB ICD-10 list (publication 2013).

14

6.12 Hospitalisation and authorisation

Members are able to obtain authorisation 24-hours a day from our Pre-Authorisation call centre (0861 111 778).

All hospital admissions and other benefits requiring approval are subject to pre-authorisation, Scheme rules, benefit schedules and managed care policies, protocols and formularies. Authorisation must be obtained from the Scheme at least 72-hours in advance for all non-emergency hospital admissions and procedures. In the case of true emergency admissions, authorisation must be obtained from the Scheme within 48-hours or on the first working day after admission.

Pre-authorisation should ideally be obtained 14 days prior to an elective admission to allow time for any outstanding information to be submitted.

Note:• Authorisation does not imply recognition of a PMB

until proof of such clinical status has been received by the Scheme. This may include clinical motivation with supporting documentation such as laboratory reports, imaging etc.

• Laparoscopic and similar endoscopic procedures are excluded from benefits, unless pre-authorised otherwise under Scheme protocols. All PMB diagnoses require proof of clinical PMB status and Scheme protocols apply.

6.13 Co-payments

Members need to pay the co-payment amounts upfront to the hospital when they are admitted for the procedures.

Co-payments do not apply if these procedures are performed out-of-hospital or when it is a PMB condition unless another option to a procedure-associated co-payment is available. When two related co-payments are simultaneously applicable, only the larger will apply. When two unrelated co-payments are applicable, both will apply. Specialised radiology co-payments apply irrespective of hospitalisation and other co-payments.

The following applies to those options with hospitalisation limited to DSP hospital networks:

• Involuntary admissions (emergencies requiring immediate treatment without delay, or those where treatment is not available at a DSP) will not incur a co-payment.

• Elective procedures and booked cases at non-DSP hospitals will incur a R3 300 co-payment in addition to co-payments applicable to the relevant procedure.

• Members are thus urged to make use of the DSP hospital networks to avoid unnecessary expenses.

• Specialist providers should be selected in association with those available at DSP hospital networks to avoid any inconvenience and co-payments.

Please visit www.resomed.co.za for a list of DSP hospital networks and providers.

Note:Please refer to your option’s Benefit Schedule booklet for a detailed breakdown of applicable co-payments.

6.14 Other insured benefits

Authorisation must be obtained in advance from the Scheme for all hospitalisation and other insured benefits. No benefits shall be granted for:

• The replacement of existing external medical appliances without satisfactory proof that the existing item is unserviceable.

• Costs of maintenance, spares or accessories. • Hospice care, rehabilitation and step-down facilities

include accommodation and visits by a medical practitioner, except where inclusive global fees are applicable.

Note:Certain insured benefits are pro-rated for members who join during the course of the year, both in benefit value and number of visits and retrospectively for those members who resign during the course of the year.

16

6.15 External medical appliances sub-limits

Note: • Subject to Scheme rules, policies and protocols.• Benefits will be pro-rated in proportion to the period of membership.

EXTERNAL MEDICAL

APPLIANCESSUPREME MILLENNIUM CLASSIC PROGRESSIVE

FLEX HOSPITAL FOUNDATION

Annual limit R12 700 per family.

R9 540 per family. Subject to PMBs.





Artificial eyes (5-year cycle)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Artificial larynx (5-year cycle)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Artificial limbs (5-year cycle)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Back supports (annual) R3 800 R3 600 R3 450 R3 310 R3 310 R1 685

CPAP Machine (3-year cycle only at DSPs)

R8 210 R7 310 R6 350 R3 310 R3 310 R1 685

Crutches (annual) R625 R625 R625 R625 R625 R625

Disposable bladder and intestinal excretion bags (annual)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Elastic stockings for varicose veins (annual)

R625 R625 R625 R625 R625 R625

External breast prosthesis after mastectomy (annual)

R1 260 R1 260 R875 R875 R875 R875

Glucometers (3-year cycle)

R1 100 R850 R690 R625 R625 R625

Hearing aids (annual, 3-year lifespan / appliance)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Home oxygen (annual, only at DSPs)

R12 700 R9 540 R6 350 R3 310 R3 310 R 1 685

Leg, arm and neck supports (annual)

R875 R800 R690 R625 R625 R625

Nebulisers / humidifiers (3-year cycle)

R1 100 R800 R690 R625 R625 R625

Orthopaedic footwear (annual)

R1 000 R850 R625 R625 R625 R625

Sleep apnoea monitors (infants < 1 year and only at pharmacy, 1 /beneficiary/life)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Wheelchairs (3-year cycle)

R6 360 R5 300 R4 240 R3 310 R 3 310 R1 685

17

6.16 Childhood immunisations

The following schedule is recommended by the National Department of Health up to the age of 18 months.

Note:Only applicable to certain options. Please refer to preventative care benefits.

AGE OF CHILD VACCINE REQUIRED

At birth OPV(1) Oral Polio Vaccine

BCG Bacilles Calmette Vaccine

6 Weeks OPV(2) Oral Polio Vaccine

DTP/Hib(1) Diptheria, Tetanus, Pertussis & Haemophilus influenza Type B vaccine

Heb B(1) Hepatitis Vaccine

PCV(1) Pneumococcal Conjugated Vaccine


RV (1) Rotavirus Vaccine





RV (2) Rotavirus Vaccine




9 Months Measles Vaccine(1)

18 Months OPV(5) Oral Polio Vaccine

DTP Diptheria, Tetanus, Pertussis

Measels Vaccine (2)

7. Late joiner penaltiesLate joiner penalties are additional premiums for persons joining medical schemes late in life which will be added to the applicable option contribution rates. Premium penalties will be applied as follows in respect of persons over the age of 35 years, who were without creditable coverage for the period indicated hereunder after the age of 30 years:

• 1 – 4 Years: 0.05 multiplied by the relevant option’s contribution.



• 25+ Years: 0.75 multiplied by the relevant option’s contribution.

Rule 4.26 “Creditable coverage” - any period during which a late joiner was a:

4.26.1 Member or dependant of a medical scheme.4.26.2 Member or dependant of any entity doing the business of a medical scheme which, at the time of membership of such entity, was exempt from the provisions of the Act.4.26.3 Uniformed employee of the South African Defence Force, or a department of such employer, who received medical benefits from the South African National Defence Force.4.26.4 Member or a dependant of the Permanent Force Continuation Fund, but excluding any period of coverage as a dependant under the age of 21 years.

8. DefinitionsAIDSAcquired Immune Deficiency Syndrome or Acquired Immunodeficiency Syndrome.

ATBAbove Threshold Benefit (Millennium option).

Benefit rateThe rate at which providers are funded as specified in the benefit schedule. The benefit rate refers to the contracted (individual) rate or a percentage of the Scheme rate.

BHFBoard of Healthcare Funders.

BPHBenign Prostatic Hypertrophy.

CAT / CT scanComputerised Axial Tomography scan.

CDL Chronic Disease List. Diagnoses, medical management and medication to the extent that this is provided for by way of a therapeutic algorithm for specified conditions, published by the Minister by notice in the Gazette.

CMSCouncil for Medical Schemes.

Contracted rateThe fee or rate at which providers contracted to the Scheme are funded.

DSPDesignated Service Provider.

ExclusionsThe Scheme’s general and option-specific list of condition and procedure exclusions.

GPGeneral Practitioner.

GRP Generic Reference Price. The price the Scheme funds as a representative price for identical active medication ingredients. All medication above the GRP is subject to a co-payment.

HIVHuman Immunodeficiency Virus.

HRTHormone Replacement Therapy for female menopause.

ICONIndependent Clinical Oncology Network.

MAVMaximum Allowed Value. The Maximum Allowed Value refers to medicines with an equally effective, less costly alternative on the medicine formulary. The price can be referenced on either a generic or therapeutic substitute. Reimbursement for items with an MAV is limited to the listed price and members will have a co-payment for products above this price. This pricing structure allows more flexible and individual patient preference.

MRI scanMagnetic Resonance Imaging scan.

MSAMedical Savings Account (Millennium option). At the beginning of each year, a set Rand amount will be allocated to the MSA. The funds allocated can be used throughout the benefit year with remaining amounts carried over to the next year.

Network providerA healthcare provider or group of providers selected by the Scheme as designated or preferred providers for diagnosis, treatment and care.

OTCOver-the-counter medicine, i.e. schedule 0, 1 or 2 medication.

19

PMBPrescribed Minimum Benefits. A list of 271 conditions that all medical schemes have to cover in terms of the Medical Schemes Act. To view this list, visit the CMS website at www.medicalschemes.com.

Pro-rated benefitsBenefit entitlement calculated according to the duration of membership during a benefit year.

PSAProstate Specific Antigen.

Regulation 8 (3)Regulation 8 (3) in terms of the Medical Schemes Act, No.131 of 1998.

Reso BabyMaternity benefit programme.

RPLReference Price List.

Scheme protocolsDocumentation that determines the Scheme’s funding.

Scheme rateThe reference base rate the Scheme allocates for a specific tariff or relevant health service. This amount is calculated based on historic fee structures in the Scheme and is adjusted annually, bound by CPI.

All providers will be funded at Scheme rates unless the specific provider is contracted to deliver services at a contracted fee. Such contracts will govern the contract of services and therefore no co-payments or administration fees may be charged to members.

The Scheme rate or contracted rates govern all funding, including PMBs, except in true emergencies which require immediate treatment without any delay, or involuntary admissions, which will be limited to 300% of Scheme rate for non-contracted providers. Otherwise, additional fees charged by non-contracted providers are for the member’s account and CMS regulations will apply.

Fees can be viewed only after member login on www.resomed.co.za with member number and specific procedure and / or tariff codes. To avoid possible co-payments and levies, members are urged to utilise contracted providers which are listed on www.resomed.co.za.

SEPSingle Exit Price. The industry reference price for medication.

SPGSelf Payment Gap (Millennium option). The gap between accumulated savings and the threshold amount.

TTOTo Take Out. Medicines received on discharge from hospital.

20

Date post:	19-Jun-2015
Category:	Health & Medicine
Upload:	resolution-health
View:	587 times
Download:	4 times

Resolution Health Medical Scheme Membership Guidelines

Health & Medicine