2018 GUIDE TO YOURHEALTH - Our Health – Our …

1 2018 GUIDE TO YOURHEALTHAQUARIUM & MARINE 1 POLMED 2018 GUIDE to your Health 2 POLMED 2018 GUIDE to your HealthCONTENTSCONTENTSBENEFIT MANAGEMENT 3 aquarium 47 Annexure B1: aquarium 47 Annexure B3: aquarium schedule of contributions (1 April 2017 31 March 2018 ) 49 Annexure B3: aquarium schedule of contributions (1 April 2018 31 March 2019) 50 General rules 51 Definition of terms 55 ANNEXURES 33 Annexure C: Acute medication exclusions 33 General exclusions 37 Prescribed minimum benefits (PMBs) 39 Annexure D:Procedures pre-authorised under the auspices of managed healthcare 40 Annexure E: Preventative healthcare benefit 2018 44 MARINE 7 Annexure A1: Marine 7 Annexure A3: Marine schedule of contributions (1 April 2017 31 March 2018 ) 9 Annexure A3.

2 Marine schedule of contributions (1 April 2018 31 March 2019) 10 General rules 11 Definition of terms 15 Marine benefit schedule 17 General benefit rules 17 In-hospital benefits 19 Overall out-of-hospital benefits 22 Stand-alone benefits 25 Annexure A2: Co-payments 30 Annexure A4: Marine chronic conditions 31 DISCLAIMERSS cheme rules are subject to approval by the Council for Medical information will never be shared with any person without your verbal or written consent.!CONTENTSADMINISTRATION 73 Access your personal information via our website 73 Application for Ex Gratia 75 Application for membership 77 Dispute resolution 81 Five easy steps to plan selection 83 Healthcare fraud is real: Fraud awareness 85 How to submit a claim 87 Member queries 89 POLMED Chat (weekdays 7:30 17.)

3 00) 91 Your step-by-step GUIDE to the 24-hour telephonic self-help service 93 MANAGED CARE 95 Authorisation for appliances and prolonged care 95 Chronic medicine management 97 Hospital pre-authorisation 99 Maternity Programme 101 Mental Health Programme (for all members) 102 Oncology management 103 Prescribed minimum benefits 105 Psychological benefits for serving members only 106 Registration to Disease Risk Management (DRM) Programme 107 Registration to HIV Management Programme 108 Specialised dentistry 109 INJURY ON DUTY (IOD) 111 MOTOR VEHICLE ACCIDENT (MVA) CLAIMS 113 CONTACT DETAILS 115 Client service contact details and regional offices 115 Designated service providers (DSPs) 119 Managed healthcare contact details 120 aquarium benefit schedule 57 General benefit rules 57 In-hospital benefits 59 Overall out-of-hospital benefits 62 Specialised dentistry 65 Stand-alone benefits 66 Annexure B2: Co-payments 70 Annexure B4: aquarium chronic conditions 71 BENEFIT MANAGEMENTBENEFIT MANAGEMENT3 POLMED 2018 GUIDE to your Health4 POLMED 2018 GUIDE to your HealthBENEFIT MANAGEMENTKeep a record of your overall out-of-hospital medical claims in the table below and overleaf, and monitor benefits available for the remainder of the year.

4 This tool will assist you to monitor the benefit categories from which your claims have been paid. This tool can be used to monitor claims for services that you did not access and will assist you to identify potential fraudulent services listed on pages 22 to 24 (Marine) and 62 to 64 ( aquarium ) under overall out-of-hospital (OOH) benefits will be paid from the amounts shown next to the member categories, : M0 member with no dependants M+1 member with one dependant M+2 member with two dependants M+3 member with three dependants M+4/more member with four or more member with no dependants (M0) who is on Marine will have R20 143 OOH benefits for the year.

5 Claims for services listed as sub-limits and that indicate Subject to OOH limit are paid from this amount. Each time the benefit is accessed the cost will be deducted from the R20 143. The benefit limit amounts are different for members with one or more dependants and for members on DESCRIPTION (Refer to Marine or aquarium benefit schedule to identify the overall out-of-hospital benefit .)LIMITSUB-LIMITUSEDAVAILABLEOVERALL OUT-OF-HOSPITAL (OOH) BENEFIT (Benefit amount allocated at the beginning of the year.) BENEFITS SUB-LIMITS (Paid from OOH limit) (The amounts reflected in this booklet can be listed in the SUB-LIMIT column and will change if/when the benefits have been accessed. This should not be added to OVERALL OUT-OF-HOSPITAL BENEFIT , but instead deducted to determine the balance left at any given time of the year.)

6 Medication AcuteMedication Over the counterPathologyPhysiotherapyRadiologySo cial workerCONSULTATIONS (Paid from OOH limit)Consultations and visits General practitioners (GPs)Consultations and visits SpecialistsOVERALL OUT-OF-HOSPITAL (OOH) BENEFIT AVAILABLE (Amount left after claims for services listed under OVERALL OUT-OF-HOSPITAL BENEFIT have been paid.)Here is another example, but this time for a member with one dependant on Marine: OOH benefit: M+1 = R24 513, which is available at the beginning of the year Claim for pathology (blood test): Claim for R878 paid by POLMED Balance left over in OOH benefit after payment of the claim = R23 635 Any claims for services listed below will be deducted from the OOH benefit on Marine.

7 If you are on aquarium , please refer to pages 62 to 64. audiology dentistry (conservative and restorative) general practitioner consultations medication (acute) medication (over the counter) occupational and speech therapy pathology physiotherapy social workers specialist MANAGEMENTBENEFIT MANAGEMENT5 POLMED 2018 GUIDE to your Health6 POLMED 2018 GUIDE to your HealthBENEFIT DESCRIPTION (Refer to Marine or aquarium benefit schedule to identify the overall out-of-hospital benefit .)LIMITSUB-LIMITUSEDAVAILABLEOVERALL OUT-OF-HOSPITAL (OOH) BENEFIT (Benefit amount allocated at the beginning of the year.) BENEFITS SUB-LIMITS (Paid from OOH limit) (The amounts reflected in this booklet can be listed in the SUB-LIMIT column and will change if/when the benefits have been accessed.)

8 This should not be added to OVERALL OUT-OF-HOSPITAL BENEFIT , but instead deducted to determine the balance left at any given time of the year.)Medication AcuteMedication Over the counterPathologyPhysiotherapyRadiologySo cial workerCONSULTATIONS (Paid from OOH limit)Consultations and visits General practitioners (GPs)Consultations and visits SpecialistsOVERALL OUT-OF-HOSPITAL (OOH) BENEFIT AVAILABLE (Amount left after claims for services listed under OVERALL OUT-OF-HOSPITAL BENEFIT have been paid.)7 POLMED 2018 GUIDE to your Health 8 POLMED 2018 GUIDE to your HealthSCHEDULE OF BENEFITS WITH EFFECT FROM 1 JANUARY 2018 Subject to the provisions contained in these rules, including all Annexures, members making monthly contributions at the rates specified in Annexure A3 shall be entitled to the benefits as set out herein, with due regard to the provisions in the Act and Regulations in respect of prescribed minimum benefits (PMBs).

9 ANNEXURE A1 MARINE SCHEDULEMARINER eference in this Annexure and the following Annexures to the term:Benefits for the services outside the Republic of South Africa (RSA)The Scheme does not grant benefits for services rendered outside the borders of the RSA. It remains the responsibility of the member to acquire insurance cover when travelling outside the borders of the RSA. POLMED rate shall mean: 2006 National Health Reference Price List (NHRPL) adjusted on an annual basis with Consumer Price Index (CPI). Agreed tariff shall mean: The rate negotiated by and on behalf of the Scheme with one or more POLMED 2018 GUIDE to your Health 10 POLMED 2018 GUIDE to your HealthANNEXURE A3 MARINE CONTRIBUTION SCHEDULEThe monthly contributions are payable by or on behalf of the member per registered RATES MARINE 2017 (1 APRIL 2017 31 MARCH 2018 )MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION)INCOME CATEGORYMEMBERADULTCHILDR0 R5 94027427469R5 941 R8 160380380127R8 161 R9 970 420420157R9 971 R11 660495495198R11 661 R13 570 578578229R13 571 R16 320661661271R16 321 R20 030728728315R20 031 +792792347 TOTAL CONTRIBUTION (EXCLUDING EMPLOYER SUBSIDY)

10 INCOME CATEGORYMEMBERADULTCHILDR0 R5 9401 9541 954909R5 941 R8 1602 0602 060967R8 161 R9 970 2 1002 100997R9 971 R11 6602 1 752 1 751 038R11 661 R13 570 2 2582 2581 069R13 571 R16 3202 3412 3 4 11 1 1 1R16 321 R20 0302 4082 4081 155R20 031 +2 4722 4721 187 The contributions for 2018 as set out in Circular 45 of 2017 by the Council for Medical Schemes (CMS).CONTRIBUTION RATES MARINE 2018 (1 APRIL 2018 31 MARCH 2019)MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION)INCOME CATEGORYMEMBERADULTCHILDR0 R6 27929529574R6 280 R8 625409409137R8 626 R10 538 452452169R10 539 R12 325532532213R12 326 R14 343 621621246R14 344 R17 250711711291R17 251 R21 172783783339R21 173 +851851373 TOTAL CONTRIBUTION (EXCLUDING EMPLOYER SUBSIDY)INCOME CATEGORYMEMBERADULTCHILDR0 R6 2792 0872 087970R6 280 R8 6252 2012 2011 033R8 626 R10 538 2 2442 2441 065R10 539 R12 3252 3252 3251 109R12 326 R14 343 2 41 42 41 41 142R14 344 R17 2502 5032 5031 188R17 251 R21 1722 5752 5751 235R21 173 +2 6442 6441 269 NOTE.