MUMED Information and Benefit Guide 2018
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/ DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION /
CompCare Wellness Medical Scheme
MUMED
Information and Benefit Guide 2018
VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING /
CompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd
The MUMED option is a traditional option that offers
above average cover, with unlimited hospital cover
and day-to-day benefits consisting of flexible risk cover.
Additional cover for specified services are available once
the flexi risk benefit is exhausted.
CompCare Wellness Medical Scheme
MUMED
Information and Benefit Guide 2018
DAY-TO-DAY BENEFITS ARE SUBJECT TO:
• Annual Flexi Benefit (AFB)
BENEFITS NOT SUBJECT TO AFB
• Wellness and Preventative Benefits
• Ambulance Services Netcare911
HOSPITAL BENEFIT
•Unlimited cover for in-hospital and hospital-related
services
ACHIEVE YOUR OPTIMAL HEALTH
WITH COMPCARE WELLNESS MEDICAL SCHEME
IN-HOSPITAL BENEFITS
Hospitalisation Hospital related accounts
Members have full access to all private hospitals throughout South Unless otherwise indicated in-hospital related benefits are unlimited
Africa. All hospital accounts are paid in full at a rate agreed between and accounts are paid at 100% of the Scheme rate. These include
the Scheme and the individual hospital groups. but are not limited to:
• General Practitioner visits
In the case of elective admissions, authorisation must be obtained • Radiology
at least 48 hours before a beneficiary is admitted to a hospital or day • Pathology
clinic, failing which a co-payment of R2 000 per admission will apply. • Surgical procedures
Late authorisations will require a R1 000 co-payment. • Blood transfusions
• Auxiliary services (i.e. physiotherapy)
In the event of a medical emergency the Scheme must be notified • Sports injuries
within one working day following the admission, failing which a co-
payment of R500 per admission will apply.
Specialist accounts with the exclusion of dental accounts relating to
CompCare Pre-authorisation / 0860 111 090 hospital admissions are unlimited and paid at 100% of the scheme
rate.
Co-payments are payable on specified elective procedures (excluding
PMBs*) done in a hospital or a day facility.
Physiotherapy in hospital is limited to R6 315 per family.
*PMB = Prescribed Minimum Benefit as defined in the Medical
Schemes Act No 131 of 1998.
While in hospital medicine is unlimited, medicine prescribed on
For the co-payment schedule, please refer to www.compcarewellness.co.za. discharge (Medicine TTO) is limited to a supply of seven days. Non-
PMB medicine is subject to the reference pricing.
Maternity benefits
Expecting mothers have access to 12 Antenatal consultations with Biological agents and specialised medicines are limited to R130 500
a GP or specialist which are paid from risk (not from the Day-to-Day per family. A 25% co-payment is applicable. These medicines can only
benefits). be obtained if pre-authorised.
Confinements are subject to clinical protocols. Ultrasound pregnancy
scans are limited to two 2D scans. Surgical Prostheses (e.g. artificial joints, stents, artificial limbs) and
electronic/nuclear devices (e.g. pacemaker, defibrillators, nerve
Expecting mothers are encouraged to register on the maternity stimulators and cochlear implants) are limited to an overall limit of
programme and receive a baby bag. Please also remember to obtain R38 650 per family. Sub-limits per sub-category apply. Sub-limits
pre-authorisation for the confinement. can be viewed on the CompCare website or obtained from the
CompCare Call Centre.
CompCare Pre-authorisation / 0860 111 090
Specialised radiology includes MRI, CT scans and high resolution
PET scans and is limited to R23 150 per family per annum. Pre-
Mental health benefits
authorisation is required for all MRI and CT Scans. High resolution
Psychiatric hospitalisation is limited to 21 days in a psychiatric facility
CT Scans/PET Scans are subject to special medical motivation and
or mental health institution.
also requires pre-authorisation. There is no benefit for unauthorised
scans, except for PMBs. No benefits are available for screening or
Non-Psychiatric hospital admissions are limited to R2 105 per family.
investigative purposes.
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 The following alternatives to hospitalisation are available subject
are covered in full for PMB conditions only: to pre-authorisation and protocols and unlimited unless otherwise
specified:
• Organ and tissue transplants
• Renal dialysis • Step-down nursing facilities, hospice and rehabilitation
• Plasmapheresis • Terminal care (Imminent death, regardless of diagnosis)
• Out-of-hospital surgical procedures
Pre-authorisation is required and protocols apply. • 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
DAY-TO-DAY BENEFITS
Annual Flexi Benefit (AFB) AFB Values for 2018
We pay your day-to-day medical expenses from the available funds
in your AFB. P A C
The AFB is a risk benefit. AFB R5 658 R3 549 R1 408
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 Cover
When you run out of AFB, we will pay for specified healthcare expenses from risk. These include:
• GP visits (balance of consultations only)
CHRONIC CONDITIONS
The MUMED option provides cover for 36 chronic conditions.
These include 26 conditions from the Chronic Disease List (CDL) as published in the Medical Scheme Act and 10 chronic conditions not listed as CDLs.
For a list of chronic conditions covered in the Mumed option, please refer to www.compcarewellness.co.za.
CDL and Non-CDL chronic conditions are subject to the AFB. Once the benefit is depleted, CDL medicines are unlimited.
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 Non-CDL chronic medicines are paid from the member’s available AFB.
price of the medicine is equal or less than the reference price for the
product. Thereafter medicines are unlimited.
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
DAY-TO-DAY BENEFITS SUBJECT TO AFB
All benefits are paid at 100% of the Scheme rate unless otherwise specified.
Benefits paid from available
Sub-limits while AFB funds
AFB where no sub-limits are
are available
applicable
M: 6 visits;
M+1: 8 visits:
GP Consultations, procedures and materials
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, failure
which will result in a 30% co-payment. No referral required 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 authorised
Acute 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
R160 per event, R560 per
Over the counter medicine (OTC) and homeopathic medicine beneficiary per annum and
R1 000 per family per annum
Basic radiology
Including black and white X-rays and ultrasound
Combined in-and-out of
Specialised radiology hospital benefit, limited to
MRI, CT, High resolution CT and PET scans R23 150 from in-hospital
benefit
Subject to AFB, combined
in-and-out of hospital
Pathology
benefit, limited to R28 940
per family
Dentistry
Conservative and restorative
Specialised dentistry
Dentures, crowns, bridgework, metal fillings and inlays, orthodontics, prosthodontics, Sub-limit of R1 950 per
periodontics, Osseo integrated implants including the cost of the appliances and beneficiary
prosthesis, maxillofacial and oral surgery
Optometry One test per beneficiary
Consultations every second year
R1 520 per beneficiary and
Optometry
R4 340 per family every
Lenses, contact lenses and disposable lenses
second year
R765 per beneficiary every
Optometry
second year, included in
Frames
lenses limit
Auxiliary services
Including audiologist (to be recommended by a medical practitioner), chiropractors,
R1 895 per beneficiary and
Dieticians, homeopaths (Consultations), Naturopaths (Consultations), Speech and
R3 000 per family
Occupational therapists, Chiropody/ Podiatry, Social workers, Physiotherapy and
Biokineticists
Mental Health- Clinical psychologists R1 575 per family
Mental Health - Psychiatry R4 000 per family
Oxygen-home ventilation
Private nursing homes Limited to 60 days per family
12 ante-natal classes, limited
Ante-natal classes
to R715 per pregnancy
Surgical and medical appliances
Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators
DAY-TO-DAY BENEFITS PAID FROM RISK
Emergencies Psychosocial counselling benefit
Ambulance services- Emergency roadside assistance and ambulance Unlimited telephonic counselling sessions with a psychologist or
transportation. social worker with the option of referral for one-on-one sessions with
qualified psychologists or social workers to a maximum of 3 sessions
NETCARE: 082 911 per beneficiary per annum.
In the case of non-emergency cases, authorisation must be obtained Benefit relates to psychosocial counselling related to substance
from Netcare911 at the time of transportation or within 24 hours abuse, emotional stress, major life events e.g. birth, accidents and
thereof, failing which will result in a 25% co-payment. death, separation and loss, health care concerns, family or personal
relationship issues, concerns about eldercare, childcare, parenting
Hospital emergency room / Casualty emergency visits not requiring issues, family violence, harassment, work related stress, balancing
admission are paid from and limited to the member’s AFB. work and family, etc.
Hospital emergency room / Casualty emergency visits resulting in a Services provided by DSP Network of psychologists and social
hospital admission will be paid from the in-hospital benefit. workers.
Hospital emergency room / Casualty emergency visits as a result of CompCare Care Counsellors / 0800 390 003
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 050 per event.
WELLNESS AND PREVENTATIVE BENEFITS
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 R180 per event.
• Mammograms - one test per female beneficiary over the age of 35 HEALTHY LIFESTYLE BENEFITS
every second year. • Fitness assessment and exercise prescription – members have
• Pap smears- one test per female over the age of 18 per annum. access to the Universal Network of biokineticists for an annual fitness
• PSA (Prostate Specific Antigen)- one test per male beneficiary over the assessment, exercise prescription and regular monitoring benefits.
age of 40 per annum. Pre-authorisation is required and protocols apply.
• Dental- one check-up per beneficiary per annum. • Fitness assessment for pregnant women – members have access to
• Glaucoma test- one test per beneficiary per annum. one fitness assessment per pregnancy. Pre-authorisation is required
• Baby wellness visits - two visits per annum for children between 4 and protocols apply.
weeks and 18 months. • Nutritional assessment and healthy eating plan – members have
• Hearing and eye tests- one hearing and eye test for pre-school children access to the Universal Network of dieticians for annual assessment,
aged 5 to 6 years. healthy eating plan prescription and regular monitoring benefits.
• School Readiness Assessment (examination for admission to Pre-authorisation is required and protocols apply.
educational institution only tariff codes 86211 and 86290 qualify). • Nutritional assessment for pregnant women – once per pregnancy.
• Career Guidance (only tariff code 86211 and 86290 qualify).
Other preventative benefits
Vaccinations and immunisations • Oral contraceptives - limited to R126 per beneficiary per month.
• Flu vaccinations- one dose per beneficiary per annum. Formulary and Reference Pricing applies.
• HPV (cervical cancer) vaccine - one course (3 doses per registered • Malaria Prophylaxis (prevention medicine) as required.
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.
VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS /
COMPCARE WELLNESS
MEDICAL SCHEME
This brochure is a summary
of the benefits of CompCare
CONTACT US
CompCare Wellness Medical Scheme
Wellness Medical Scheme.
Universal Place, 19 Tambach Road,
All information relating to
Sunninghill Park, Sandton
the 2018 CompCare Wellness
PO Box 1411, Rivonia, 2128
Medical Scheme benefits
and contributions are subject
Tel: 0861 222 777 / Fax: 0866 450 991
to formal approval by the
E-mail: correspondence@universal.co.za
Council for Medical Schemes.
Web: www.compcarewellness.co.za
On joining the Scheme,
all members will receive a
Contact details for complaints escalated to the Council for
detailed member brochure, as
Medical Schemes
approved. The final registered
Tel: 0861 123 267
Rules of the Scheme will apply.
E-mail: complaints@medicalschemes.com
Web: www.medicalschemes.com
CompCare Wellness Medical
Schemes is administered
by Universal Healthcare
Administrators (Pty) Ltd.
GLOSSARY
A – Adult Dependant
AFB – Annual Flexi Benefit
C – Child Dependant
CDL – Chronic Disease List
DSP – Designated Service Provider
OTC – Over the Counter Medicine
P – Principal Member
PMB – Prescribed Minimum Benefits
PMF – Per Member Family
TTO – To Take Out (Medicine taken on discharge from hospital)
Contributions Effective from 1 January 2018 Annual Benefit Amounts for 2018
Principal Adult Child Principal Adult Child
Member Dependant Dependant Member Dependant Dependant
Monthly R2 772 R2 160 R780 Annual Flexi Benefit R5 658 R3 549 R1 408
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.
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