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2012 POLMED BENEFITS
POINTS TO CONSIDER WHEN
CHOOSING THE LOWER PLAN:
E It is important that family medical history is taken into account when choosing a plan.
E Members may only be hospitalised in designated service provider (DSP) hospitals.
E You will be liable for a co-payment of R8 000 if you are hospitalised in a non-DSP hospital.
E The plan offers reasonable out-of-hospital limits.
E It is intended for families who have little healthcare needs – generally healthy families.
E It is also intended for members whose chronic conditions are under control.
E It is not intended for members who seek medical assistance on a regular basis.
E Certain benefits will not be funded while in hospital – refer to in-hospital benefits.
E Changing to another plan can only happen once per year – before 31 December.
Client Service Centre:
Health Advice Line:
Tel: 0860 765 633 or 0860 POLMED Tel: 0860 104 111 Fax: 0860 104 114 Fraud hotline:
Tel: 0800 200 564 Fax: 0861 888 110 Emergency Medical Assistance –
Confidential HIV/AIDS line:
Netcare 911:
Tel: 0860 104 112 Fax: 0861 113 136 Specialised dentistry pre-authorisation:
E-mail address for submitting enquiries:
Tel: 0860 104 111 Fax: 0861 113 138 Chronic Medicine Management:
POLMED website:
Tel: 0860 765 633 Fax: 0861 113 134 Hospital pre-authorisation:
POLMED mobile website:
Tel: 0860 104 111 Fax: 0861 113 133 http://m.polmed.co.za(This service is available via your cell phone.) Pre-authorisation is required for items funded from the chronic All admissions to hospitals, day clinics and out-patient units medication benefit. Pre-authorisation is based on evidence- must be pre-authorised, otherwise a penalty of R1 000 will be based medicine principles and the funding guidelines of the Scheme. The member needs to re-apply at least one month prior to the expiry of the existing chronic medication In the case of an emergency, the Scheme must be notified within 48 hours or on the first working day after the admission.
The Scheme shall only consider claims for medicines obtained Pre-authorisation will be managed under the auspices of on the written prescription of a person legally entitled to managed healthcare.
prescribe medicine and dispensed by such person or a registered pharmacist.
The appropriate facility has to be used to perform a procedure, based on clinical requirements and the expertise of the doctor Flu vaccines are obtainable without a prescription.
doing the procedure.
Benefits for semi-private rooms are excluded unless they are Specialist referral motivated and prior approval is obtained, as clinically essential.
All POLMED beneficiaries need to be referred by a general practitioner to a specialist. The Scheme will impose a co- Medicine prescribed during hospitalisation forms part of payment of up to R500 if the specialist does not reflect the hospital benefits. Medicine prescribed during hospitalisation referring general practitioner's name on his/her account. The to be taken out (TTO) will be paid to a maximum of seven days' co-payment will be payable by the member to the specialist and is not refundable by the Scheme.
Maternity: The costs incurred in respect of the newborn baby This co-payment is not applicable to the following specialities/ shall be regarded as part of the mother's cost for the first 90 disciplines: gynaecologists, psychiatrists, oncologists (cancer), days after birth. If the child is registered on the Scheme within ophthalmologists, nephrologists (dialysis) and dental specialists.
90 days from birth, Scheme Rule 7.1.2 shall apply.
The Scheme will allow two specialists' visits per beneficiary per Benefits shall also be granted if the child is stillborn.
year – that do not require general practitioner referral – to cater for those who clinically require annual and/or bi-annual specialist visits.
Specialised radiology Pre-authorisation is required for all scans. In the case of an emergency the Scheme must be notified within 24 hours or Ex gratia benefit on the first working day following the admission or start of The Scheme may, at the discretion of the Board of Trustees, treatment, failing which the Scheme will impose a co-payment grant an ex gratia payment upon written application from of R500 per procedure.
members, as per the rules of the Scheme.
Pro rata benefits Prescribed minimum benefits (PMBs) for chronic medication The maximum annual benefits that are referred to in this shall be subject to registration on the Disease Risk Management schedule shall be calculated from 1 January to 31 December Programme for those conditions that are managed, as well as each year, based on the services rendered during that year and chronic medication rules.
shall be subject to pro rata apportionment calculated from the admission date of the member to the Scheme to the end of that Payment will be restricted to one month's supply in all cases financial year.
for acute and chronic medicine, except where the member can submit proof that more than one month's supply is necessary due to travel arrangements to foreign countries. (Travel Designated service provider (out-of-network documents must be submitted as proof.) Payment of medicine will be limited to the POLMED Maximum A designated service provider (DSP) is a healthcare provider Allowed Cost on both the acute and the chronic benefit (or group of providers) selected by the Scheme as preferred categories, where the item is listed on the chronic diseases list. providers for the diagnosis, treatment and care in respect of one The balance needs to be funded by the member.
or more prescribed minimum benefit conditions.

DEFINITION OF TERMS Where the Scheme has appointed a DSP and the member chooses to use an alternative provider, all costs in excess of A co-payment is an amount or portion of the cost of a those agreed with the DSP (including a co-payment), will be for product or service, which is due by the member to the the cost of the member and paid directly to the provider by the provider at the point of service, e.g. consultations or admission to hospital. The co-payment is not required in the event of a life threatening injury or prescribed Examples of DSPs (where applicable) are: minimum condition.
E General Practitioner Network E Optometrist Network (Visual) E Renal (Kidney) Network POLMED Maximum Allowed Cost equivalent E Cancer (Oncology) Network E Hospital Network.
The Metropolitan Health Reference Price (MetRef) is You can access the list of providers on the POLMED website.
the reference pricing system applied by the Scheme's managed healthcare provider. This pricing system refers to the maximum price that POLMED will pay for a Designated GP Provider (Network GP) particular medication. Should a reference price be set for a medication, patients are entitled to make use of any Members are allowed two visits to a non-Network GP, i.e. a GP medication within this pricing limit, but will be required who is not part of the network, for emergency or out-of-town to make a co-payment on medication priced above the pricing limit.
Designated Pharmacy Network Specialised dentistry POLMED has appointed service providers for the provision of Specialised dentistry refers to services that are not defined chronic medication.
as basic dentistry. These include periodontal surgery, crowns and bridges, implant procedures, inlays/onlays, The Scheme utilises the courier pharmacy service as the primary indirect veneers, orthodontic treatment, removal of service provider, with the retail pharmacy providing secondary impacted teeth and maxillo-facial surgery.
support for those members who prefer personal interaction.
Where the member chooses to use an alternative provider, the member shall be liable for a co-payment of 20% of the costs paid directly to the provider by the member. You can access the list of providers on the POLMED website.

STATUTORY PRESCRIBED MINIMUM BENEFITS (PMBs)
POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
Statutory prescribed minimum benefits
100% of POLMED rate; or at According to legislation, treatment for these conditions must cost subject to motivation be funded by POLMED PMBs are minimum benefits that by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:• any emergency medical condition• a range of conditions, as specified in Annexure A of the OVERALL OUT-OF-HOSPITAL BENEFITS
POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
OVERALL OUT-OF-HOSPITAL BENEFITS
M0: R6 000 (principal This is the total amount allocated for any healthcare services received out of hospital, e.g. blood tests, doctor's visits and Benefits shall not exceed the amount set out in M1: R7 400 (principal member and 1 dependant) This amount is the maximum allocated per member or family PMBs shall accrue towards the total benefit M2: R9 000 (principal – see example below PMBs are not subject to limits M3: R9 600 (principal If you (or a beneficiary) consult a doctor, the account will be paid In appropriate cases the limit for medical from the total amount allocated to the out-of-hospital benefit appliances shall not accrue towards this limit M4+: R11 000 (principal Out-of-hospital benefit (M4+): Consultation: R230 Out-of-hospital balance for the year: R10 770The amount is allocated for the year per member or family and is pro rated depending on the member's joining date 100% of POLMED rate A R500 co-payment will be payable by the member if not Subject to referral by a general practitioner (GP) Referral to Network GP POLMED will allow 2 specialist visits per Claims will be paid if referred by a GP beneficiary per year without a referral Limited to 4 visits per Registration on the Disease Risk Management (DRM) Referral is not necessary for gynaecologists, beneficiary and 8 visits per Programme may provide additional PMBs psychiatrists, oncologists (cancer), ophthalmologists, nephrologists (dialysis) and If registered on the DRM Programme for a chronic condition, dental specialists a care plan will indicate the number of consultations that are allowed, which will not affect these visits – the treating doctor must use the codes that are on the care plan to ensure payment from the correct benefit The care plan will indicate from which benefit the consultation will be paid POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
General practitioner (GP) consultations
POLMED GP Network Consultations are paid from the out-of-hospital benefit amount Subject to a maximum number of visits/ Even if funds are left in the out-of-hospital benefit, the consultations per family per maximum number of consultations may not be exceeded annum, as follows:M0: 8 consultations The GP/specialist must have a copy of the care plan, which (principal member) will reflect the codes that must be used when submitting M1: 12 consultations a claim for a consultation that relates to a PMB chronic (principal member/ M2: 15 consultations (principal member/ Principal member: 8 consultations per year Principal member: 7 consultations used M3: 18 consultations Principal member: 1 consultation left Out-of-hospital benefit used: R11 000 (M4+) M4+: 22 consultations Principal member: 1 consultation required NO FUNDS AVAILABLE IN OUT-OF-HOSPITAL BENEFIT
– CONSULTATION WILL THEREFORE NOT BE PAID BY
POLMED DESPITE ONLY 7 CONSULTATIONS USED
NB:
If a member chooses to consult a non-network GP he/she
will be liable for a co-payment, which will be payable by the
member to the GP
Medication – acute
100% of POLMED rate The amount is only available if funds are available in the out- Subject to available funds in the overall out-of- of-hospital benefit Subject to MetRef formulary The R6 600 is not an extra amount that is added to the out- R6 600 per family of-hospital benefit R11 000 per family cannot be exceeded, even if there are funds available in the out-of-hospital benefit – see example below Example:
Out-of-hospital benefit (M4+):
Acute medication utilised: Out-of-hospital balance for the year: R4 400 The out-of-hospital balance of R4 400 that is left cannot be used for medication if the full amount of R6 600 per family for medication has been used Medication – over-the-counter (OTC)
100% of POLMED rate POLMED allows medication for which you do not require a prescription, i.e. self-medication Subject to restricted formulary This is not an additional amount for medication Maximum of R540 per family The amount can be used for OTC medication if the R6 600 per family for acute medication has not been exhausted Shared limit with acute medication POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
Medication – chronic
100% of POLMED rate at Chronic medication is medication for a condition that Subject to completion of the relevant chronic requires ongoing treatment medication application form and approval Subject to MetRef formulary The prescription must be sent to POLMED for authorisation for approved PMB-CDL before the medication can be obtained from a DSP pharmacy Medipost Courier Pharmacy Authorisation may take a few days, unlike acute medication that will be available on the same day Only medication for chronic conditions that appear on the list of conditions will be paid The member must be registered on the Disease Risk Management (DRM) Programme – the application form must be completed by both the member and his/her doctor and returned to POLMED Medication must be obtained from a DSP pharmacy to avoid or reduce any co-payment that must be made by you Where a generic medication is available and the member chooses to use the more expensive, original or brand-name medication, he/she must pay the difference in price to the pharmacy Allied health services
Includes chiropractors, dieticians, homeopaths, chiropody/podiatrists, phytotherapists, reflexologists, naturopaths, orthoptists, osteopaths and therapeutic massage therapists Benefit based on evidence-based medicine 100% of POLMED rate You must have funds available in the out-of-hospital benefit Subject to overall out-of-hospital limit to access this benefit – refer to the dental benefits further on in this benefit schedule 100% of POLMED rate Consultations and medication will be paid from the out-of-hospital amount if member is not registered on the Subject to overall out-of- Psychiatry Management Programme for depression, PTSD, bipolar mood disorder and substance abuse Stand-alone benefit New additional visits:
Doctor must complete a form to enrol a member/beneficiary 4 post-trauma briefing sessions with a psychologist or social worker If registered on the programme, the care plan will indicate the services (consultations and medication) that will be Subject to referral process and treatment protocol All information is treated as confidential Example if not registered on the programme:
Out-of-hospital benefit:
Consultation: R800Medication: Balance in out-of-hospital benefit: R8 700 Example if registered on the programme:
Out-of-hospital benefit:
In-hospital benefit: Limited to 21 days per beneficiary per year Consultation on care plan: Paid from in-hospital limitMedication authorised: Paid from chronic Balance in out-of-hospital benefit: R11 000 POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
100% of POLMED rate Will be paid if referred by a Network GP or specialist Subject to referral by GP or Funds must be available in out-of-hospital benefit to access Maximum of R3 000 per The R3 000/R7 000 is not an extra amount that is added to beneficiary and R7 000 per the out-of-hospital benefit Members may not go directly to the pathology lab for testing unless referred by a treating doctor 100% of POLMED rate Will be paid if referred by a GP or specialist Subject to referral by a Network GP or specialist Annual limit of R1 650 per Funds must be available in out-of-hospital limit to access this Subject to overall out-of-hospital limit The R1 650 is not an extra amount that is added to the out-of-hospital benefit 100% of POLMED rate Funds must be available in out-of-hospital limit to access this benefit Annual limit of R1 650 per family The R1 650 is not an extra amount that is added to the out-of-hospital benefit Subject to overall out-of-hospital limit 100% of POLMED rate Will be paid if referred by a GP or specialist (E.g. X-rays and ultrasounds) Annual limit of R2 640 per Funds must be available in out-of-hospital limit to access this Subject to referral by a GP or specialist Ultrasound scans per pregnancy Limited to three 2D scans The R2 640 is not an extra amount that is added to the out- of-hospital benefit 100% of POLMED rate This scan will only be covered if pre-authorisation was (E.g. MRI and CT scans) obtained – irrespective of whether the funds are from the 2 scans per beneficiary per out-of-hospital or in-hospital benefit Subject to pre-authorisation year combined with in-hospital limit The following information will be needed to obtain authorisation:• radiologist's practice number• treating doctor's practice number• diagnosis code, to indicate the reason for the scan• tariff code• service date The benefit per beneficiary PPN is an optometry provider appointed by POLMED to Includes frames, lenses and eye examinations (per 24-month benefit cycle) provide optical services to members 1 eye examination per beneficiary every 2 years The optometrist will charge the fee that has been agreed to (unless previously approved for clinical indication) PPN provider would be:
One composite consultation, Benefits not pro rated inclusive of a refraction, Failure to use the DSP will result in an out-of-pocket payment tonometry and visual field Each claim for lenses/frames must be submitted screening If the amount allocated for the frame/test/contact lenses with a lens prescription is exceeded, the member will be liable for payment of the difference directly to the optometrist Benefits shall not be granted for contact lenses if the beneficiary has already received a pair of A PPN frame to the value of spectacles in a 2-year period R150 or R350 towards the cost of any alternative frame Annual contact lens limit specified and/or lens enhancements and either 1 pair of clear PPN is the Preferred Provider Network Aquity single vision or clear Aquity bifocal lenses (cost of clear Aquity multi-focal lenses limited to cost of bifocal lenses) POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
Contact lenses to the value of R500 Non-PPN provider would be:
1 consultation, limited to a
maximum cost of R250
R350 frame and/or lens enhancement benefit and one pair of single vision lenses limited to R130 per lens or one pair of clear flat-top bifocal lenses limited to R290 Contact lenses to the value of R500 Subject to clinical protocols Occupational and speech therapy/
Higher Plan offers extended benefits Appliances (medical and surgical)
100% of POLMED rate and Application with quotation must be sent to POLMED to Oxygen subject to pre-authorisation authorise the appliance before it is issued Cost for maintenance is a Scheme exclusion This is the maximum amount that will be paid for a specific or R15 600 per set per Any repairs/maintenance to the appliance will not be paid by POLMED will unfortunately not replace the device if it is lost family once every 4 years A motivation letter from a service provider will be required for a motorised wheelchair family once every 4 years once every 3 years beneficiary once every 3 years POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
Appliances (medical and surgical)
catheters and accessories, stoma bags and accessories transfusion out of hospital Early detection screening The correct codes must be used by the doctor to ensure the Risk assessment tests (refer to schedule F):
limited to periods specified doctor's consultation for an annual medical examination is • annual medical examination (code 0190-0192) not deducted from the number of consultations allowed per • child immunisation member/family, as indicated in the out-of-hospital limit • cholesterol test• bone densitometry scan (DEXA scan) Members are responsible for informing the doctor that they • cervical cancer screening want an annual medical examination and request him/her to • breast cancer screening use the correct code • prostate screening • glaucoma screening The tests will be paid from the in-hospital benefit and will • glucose screening not be deducted from the out-of-hospital limit • flu vaccine • pneumococcal vaccine Correct codes must be used by the doctor to ensure • HIV test and counselling payment of the account • dental• hypothyroidism screening• oral contraceptives• hibtiter test Maternity – home birth
100% of POLMED rate You need to inform POLMED of your intention to give birth Subject to pre-authorisation Limited to R10 000 per beneficiary per annum You need to ensure that the midwife is fully trained and registered with a valid practice number to render this service Benefits relating to more than 2 antenatal ultrasound scans and amniocenteses You need to obtain authorisation from POLMED to ensure (amniotic fluid tests) after the service rendered by the midwife will be paid 32 weeks of pregnancy, are subject to pre-authorisation 100% of POLMED rate This valuable but confidential service is available to all Subject to registration on the HIV Management members and beneficiaries Case managed in accordance with treatment protocols IN-HOSPITAL BENEFITS
POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
Pre-authorisation is always required before being admitted to a hospital – phone POLMED for the authorisation number There is a penalty of R1 000 if no pre-authorisation is obtained for hospitalisation Note:
In the case of an emergency, please obtain pre-authorisation
within 48 hours or on the first working day after admission to
hospital
When you phone for pre-authorisation, POLMED will require the following:• your membership number• date of birth of patient• practice number of the admitting/treating doctor• practice number of hospital admitted to• ICD-10 code – diagnosis code• procedure code• admission date Prescribed minimum benefits (PMBs)
100% of POLMED rate at DSP; or at cost, subject to motivation when necessary Hospital procedures (co-payments)
No co-payment if the Procedure as per Annexure D procedure is performed in a DSP hospital and/or day clinic Annual overall hospital limit
100% of POLMED rate Subject to pre-authorisation Unlimited in DSP hospitals Non-PMB day admissions (excludes to-take-out (TTO) medication) R8 000 co-payment in non-DSP hospitals Unlimited for emergency and PMB conditions Not allowed in hospital Subject to dental protocols Not allowed in hospital Subject to dental protocols Emergency medical assistance
100% of POLMED rate Netcare 911 on 082 911 100% of POLMED rate Pre-authorisation required for admission Subject to registration on the HIV Management Programme Case managed according to Member must be registered on the HIV Management treatment protocols The hospital must contact POLMED if the authorised length of stay is not sufficient Chronic kidney dialysis
100% of POLMED rate at Pre-authorisation for dialysis in hospital must be obtained Subject to PMBs, pre-authorisation and registration on the Disease Risk Management Member must be registered on the DRM Programme and Subject to managed Chronic Medicine Management Programme for ongoing healthcare protocols National Renal Care (NRC) and Fresenius Medical Care are preferred providers POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
Maternity benefits (also see maternity –
100% of POLMED rate Pre-authorisation must be obtained in advance home birth)
Subject to pre-authorisation and registration on
The member must be registered on the Maternity the Maternity Management Programme Management Programme The POLMED Membership Department must be informed of the birth of the baby to facilitate its registration as a dependant Note that third generation babies (grandchildren) do not qualify for membership and their treatment in hospital will not be covered Not allowed in hospital Subject to pre-authorisation 100% of POLMED rate The treating doctor will be required to send a DSMIV form to Subject to PMBs, pre-authorisation and the psychiatric case manager registration on the Psychiatry Management Only PMBs and post- Programme for the following conditions: traumatic stress disorder • depression• bipolar mood disorder Annual limit of 21 days per • substance abuse • post-traumatic stress disorder (PTSD) 100% of POLMED rate at Non-PMB specialist drug limit (e.g. biologics) Subject to pre-authorisation Specialised medicine sub-limit of R54 000 per family Oncology (chemotherapy and
100% of POLMED rate at After a diagnosis of cancer is made, the treating doctor will radiotherapy) – cancer
be required to submit a treatment plan to the Oncology Subject to pre-authorisation and registration on Management Programme the Oncology Management Programme Limited to R180 000 per beneficiary The oncology case manager will issue authorisations for both Independent Clinical Oncology Network (ICON) consultations and investigations for a period MRI/CT scans will be funded from the oncology benefit Organ and tissue transplants
100% of POLMED rate A letter of motivation and quotations from the treating Subject to pre-authorisation and clinical doctor will be required guidelines used in State facilities No benefit except for PMBs Unlimited radiology and pathology for organ transplants and immunosuppressants 100% of POLMED rate Blood tests done in hospital when the patient was admitted Subject to protocols and clinical guidelines will be paid from the in-hospital benefit 100% of POLMED rate The admitting diagnosis should be related to the reason for Subject to pre-authorisation physiotherapy, e.g. back pain Prosthesis (internal and external)
100% of POLMED rate When planning an operation, a quotation needs to be Subject to pre-authorisation and approved approved before the operation Limited to R54 000 per beneficiary Examples of internal prosthesis:• knee and hip replacements• stents (used for heart operations)• meshes (used in hernia repairs) Example of external prosthesis:• artificial limbs

POLMED LOWER PLAN
EXPLANATION AND EXAMPLES
100% of POLMED rate The following information will be needed to obtain Subject to pre-authorisation Limited to R27 500 per family • radiologist's practice number • treating doctor's practice number Subject to a limit of 2 scans • diagnosis code to indicate reason for the scan per annum per beneficiary, including scans out of 100% of POLMED rate An example of a basic radiology test is a chest X-ray 100% of POLMED rate 150% of POLMED rate Members should confirm the anaesthetist's tariffs before the operation Where anaesthetists charge private rates that are above POLMED rates, the member will be liable for the difference ANNEXURE B2
CO-PAYMENTS
The elective procedures stipulated under Annexure D for the Lower Plan can only be performed in a DSP hospital and/or day
clinic; otherwise the following co-payments will be applicable:
Allows for 2 out-of-network visits Joint replacement Laparoscopic nissen Hospital DSP (where applicable) PHARMACY OUT-OF-NETWORk RULE
Where the Scheme has appointed a DSP and the member Endoscopy, e.g. gastroscopy chooses to use an alternative provider, the member will be liable for a co-payment of 20% of costs, which he/she must pay directly to the provider.
ANNEXURE B4
LOWER PLAN CHRONIC CONDITIONS LIST
LIST OF CHRONIC CONDITIONS: SUBjECT TO PMBs
(SUBJECT TO THE PROVISIONS IN THE ACT AND REGULATIONS IN RESPECT OF PMBs).
Coronary artery disease Rheumatoid arthritis Cardiac dysrythmias Parkinson's diseaseMultiple sclerosis Chronic obstructive pulmonary disease Affective disorders (depression and bipolar mood disorders) Schizophrenic disorders Ulcerative colitis Chronic renal failure Diabetes mellitus type IDiabetes mellitus type II SPECIAL CATEGORY CONDITIONS
Diabetes insipidus AUTO-IMMUNE DISORDERS
Systemic lupus erythematosis (SLE)
ANNEXURE E
POLMED DENTAL BENEFIT TABLE 2012 – LOWER PLAN
Dental benefits are paid at 100% of the prescribed tariff. The dental protocols and benefit rules apply to all options. All specialised
dentistry and hospitalisation must be authorised.
Routine consultations, cleaning of teeth and fluoride application Twice annually per beneficiary Oral hygiene instructions Once in 12 months per beneficiary Permanent molars up to 21 years X-rays (radiographs) Extra-oral radiography limited to a 2-year period Once per tooth within 12 months, with a maximum of 4 fillings per beneficiary per annum If more than 4 fillings are required, your dentist should submit a
dental plan for the beneficiary to POLMED
Maximum of 2 per beneficiary per annum DENTISTR
Root canal treatment If more than 2 are required, your dentist should submit a dental plan
for the beneficiary to POLMED
Surgical removal of teeth, including impacted teeth Pre-authorisation required if done in hospital (for impacted teeth only) All identified beneficiaries to be registered on the Periodontal
Programme
Root planning (non-surgical periodontal interventions) As per clinical protocolsOver the age of 12 years Once every 24 months All the above are subject to overall out-of-hospital limit
Periodontal surgery No specialised dentistry other than for PMBs Metal base to partial denture No specialised dentistry other than for PMBs Crown and bridge work No specialised dentistry other than for PMBs Orthodontic treatment No specialised dentistry other than for PMBs Maxillo-facial surgery
These procedures are paid for from the major risk benefit
No specialised dentistry other than PMBs They are subject to pre-authorisation, unless it is an emergency In all cases pre-authorisation is required, failing which the Scheme will impose a co-payment of R500
Written motivation and radiographs Children under the age of 7 years Subject to Scheme's approval Written motivation and radiographs Surgical removal of teeth Subject to Scheme's approval
Only for surgical removal of multiple impacted teeth
No benefit in hospital Periodontal surgery No benefit in hospital Written motivation and radiographs Surgical exposures of unerupted canines Subject to Scheme's approval Written motivation and radiographs Allergic to local anaesthetic Subject to Scheme's approval Written motivation and radiographs Oro-facial and dental trauma Subject to Scheme's approval Patients with either physical, mental or medically Written motivation and radiographs compromising conditions Subject to Scheme's approval Orthognathic surgery No specialised dentistry other than for PMBs ANNEXURE B3
SCHEDULE OF
CONTRIBUTIONS
The monthly contributions below are payable by or on
behalf of the member, per registered beneficiary.
The contributions for 2012 are set out below in the format required by the Registrar in circular 19. CONTRIBUTION RATES LOWER PLAN 2012 (until 31 March 2012)
TOTAL CONTRIBUTION (ExCLUDING EMPLOYER SUBSIDY) MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION) R4 051 – R5 650 R4 051 – R5 650 R5 651 – R7 000 R5 651 – R7 000 R7 001 – R8 200 R7 001 – R8 200 R8 201 – R9 650 R8 201 – R9 650 R9 651 – R11 700 R9 651 – R11 700 R11 701 – R14 500 R11 701 – R14 500 R14 501 – R18 500 R14 501 – R18 500 R18 501 – R20 800 R18 501 – R20 800 PLEASE NOTE: Where parents have been registered as dependants, the full contributions (without subsidy) will be payable.
For example, R1 069 (father) + R1 069 (mother) + R471 (member) + R471 (spouse) = R3 080 per month.
CONTRIBUTION RATES LOWER PLAN 2012 (with effect from 1 April 2012)
TOTAL CONTRIBUTION (ExCLUDING EMPLOYER SUBSIDY) MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION) R4 501 – R6 150 R4 501 – R6 150 R6 151 – R7 500 R6 151 – R7 500 R7 501 – R8 700 R7 501 – R8 700 R8 701 – R10 200 R8 701 – R10 200 R10 201 – R12 400 R10 201 – R12 400 R12 401 – R15 300 R12 401 – R15 300 R15 301 – R19 300 R15 301 – R19 300 R19 301 – R21 700 R19 301 – R21 700 PLEASE NOTE: Where parents have been registered as dependants, the full contributions (without subsidy) will be payable.
For example, R1 144 (father) + R1 144 (mother) + R481 (member) + R481 (spouse) = R3 250 per month.
ANNEXURE C – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLAN
GENERAL EXCLUSIONS
The following services/items are excluded from benefits with due regard to prescribed minimum benefits (PMBs) and
will not be paid by the Scheme:
1. Services not mentioned in the 10. Aids for participation in sport, e.g. 28. Unless otherwise indicated by the benefits, as well as services which, in Board, costs for services rendered the opinion of the Scheme, are not 11. Gold inlays in dentures and crown by any institution, not registered in aimed at the treatment of an actual work and bleaching of vital (living) terms of any law; or supposed illness or disablement 29. All costs in respect of sickness that impairs or threatens essential conditions that were specifically body functions (the process of 12. Subject to the benefits in Annexure excluded from benefits when the ageing will not be regarded as an A and B, the treatment of dental member was admitted to the illness or a disablement); Scheme for 12 months from the date 2. Sleep therapy; 13. Any orthopaedic and medical aids not mentioned in Annexure A and B; 3. Reversal of sterilisation procedures, 30. Unless otherwise decided by provided that the Board may decide 14. Reports, investigations or tests for the Board, benefits in respect to grant benefits in exceptional insurance purposes, admission to of medicines obtained on a universities or schools, fitness tests prescription are limited to one and examinations, medical court 4. The artificial insemination of a month's supply for every such reports, employment, emigration or person in or outside the human prescription or repeat thereof; immigration, etc.; body, as defined in the Human 31. Any health benefit not included Tissue Act, 1983 (Act 65 of 1983), 15. Sex change operations; in the list of prescribed benefits provided that, in the case of 16. Bandages and plasters, unless (including newly-developed artificial insemination, the Scheme's prescribed after an operation or interventions or technologies) will responsibility on the treatment will be excluded from benefits until and unless the benefits are revised to • limited to the hospital-based 17. Travelling costs except services (medical and surgical) diagnostic according to the benefits in 32. Compensation for pain and and treatment practice Annexure A and B; suffering, loss of income, funeral • as it is prescribed in a public 18. Accounts of persons not registered expenses or claims for damages; with a recognised professional body • as defined in the PMBs constituted in terms of an Act of 33. Nappies excluded and benefits • subject to pre-authorisation and for adult use will only be granted if prior approval by the Scheme authorised prior with motivation; 19. Accommodation in spas or health or 5. Charges for appointments that a 34. Benefits for organ transplant donors member or dependant failed to to recipients who are not members keep with service providers; 20. Holidays for recuperative purposes; 6. Prenatal and/or post-natal exercises; 21. The treatment of obesity, provided 35. Benefits for medical expenses that with prior motivation the sustained as a result of injuries on 7. Operations, treatments and Scheme may approve benefits for procedures, by choice, for cosmetic the treatment of morbid obesity; purposes, where no pathological 36. Claims relating to the following: substance exists that proves the 22. Muscular fatigue tests, except if • aptitude tests necessity of the procedure, and/ requested by a specialist and a or that is not life-saving, life- doctor's motivation is enclosed; • school readiness sustaining or life-supporting; for 23. Subject to the benefits in Annexure • questionnaires example breast reduction, breast A and B, the treatment of alcoholism • marriage counselling augmentation, otoplasty, total • learning problems nose reconstruction, lipectomy, • behavioural problems 24. Any treatment as a result of subcutaneous mastectomy, minor surrogate pregnancy; 37. Benefits for tints and photochromic superficial varicose veins treatment with sclerotherapy, abdominal bowel 25. Blood pressure appliances, bypass surgery, etc.; provided that the Board may decide 38. Cosmetics and sun block; to grant benefits in exceptional 8. Plastic and reconstructive surgery 39. Appliances and devices, e.g. non- is excluded from benefits, unless diabetic syringes.
prior approval by the Scheme is 26. Non-functional prosthesis used for granted as clinically essential and not reconstructive/restorative surgery, provided that the Board may decide to grant the benefits in exceptional 9. Accommodation in an old-age home or other institution that provides general care for aged and/ 27. Benefits for costs of repair, or chronically ill patients, unless maintenance, parts or accessories approved by the Scheme; for the appliances or prosthesis; ANNEXURE C – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLAN
ACUTE MEDICINE EXCLUSIONS
The following categories of medicines are excluded from acute medicine benefits:
Gender/sex related: Vitamin and/or mineral Treatment of female Multivitamins or minerals Gender/sex related: Vitamin and/or mineral Androgens and anabolic Geriatric vitamins and/or Slimming preparations Vitamin and/or mineral Patent medicines: Household remedies Tonics and stimulants Patent medicines: Vitamin and/or mineral Patent and over-the- Calcium diet supplementation Patent medicines: Vitamin and/or mineral supplements: Patent medicines: Patent medicines: Vitamin and/or mineral Soaps and cleansers Patent medicines: Vitamin and/or mineral Patent medicines: Contact lens preparations Unregistered vitamins, minerals or food Patent medicines: Patent sunscreens Naturo- and homeopathic Patent medicines: Medicated shampoo Homeopathic remedies Patent medicines: Naturo- and homeopathic Veterinary products Appliances, supplies and Topical preparations: Medical appliances/ Appliances, supplies and Veterinary products Bandages, dressings, cotton wool and gauze Medicines where cost/ Appliances, supplies and benefit ratio cannot be Herceptin Gleevac® Disposable cholesterol All newly-registered Nappies, molipants, Appliances, supplies and linen savers, except Incontinence products Other items and categories that can be excluded according to evidence-based medicine principles, as Diagnostic agents approved by the Scheme from time to time.
Other immunoglobulins ANNEXURE C – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLAN
The following categories are not available on acute medicine benefits: Gender/sex related: Treatment/prevention of Treatment of impotence/ sexual dysfunction Alcohol, except PMBs Appliances, supplies and Stoma products and accessories, except Erythropoietin, except where it forms part of PMB-related services Appliances, supplies and Haemostatics, except Medicated dressings, except where these form part of PMB-related regulators and oxygen Appliances, supplies and Surgical appliances/ products for home Treatment/prevention of ANNEXURE D – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLAN
PROCEDURES PRE-AUTHORISED UNDER AUSPICES OF
MANAGED HEALTHCARE
IF THESE PROCEDURES ARE PERFORMED IN THE
PRE-AUTHORISATION POLICIES AND PROCEDURES
DOCTORS' ROOMS THERE IS NO NEED FOR PRE-
AUTHORISATION.
Where applicable, pre-authorisation must be obtained for clinical services and will be subject to benefit limits. Within the • Any minor surgical procedure, e.g. lymph node biopsy auspices of managed healthcare, a clinical motivation might be • Breast biopsy • Cauterisation of warts• Circumcision• Cone biopsy PRE-AUTHORISATION FOR HOSPITALISATION
• Drainage of small abscesses• Endoscopy of the nose All hospital admissions must be pre-authorised (where • Excision of superficial benign tumours indicated, a hospital network will apply).
• Fine needle biopsy • You may obtain a hospital authorisation number by phoning • Ganglion excision the Hospital Risk Management Programme on 0860 104 111 • Payment to a hospital is subject to pre-authorisation, • Intra-articular hydrocortisone injection clinical necessity, appropriate treatment, benefit limits and • Laser procedures prescribed minimum benefits (PMBs).
• If you are admitted to an intensive care unit or high care • Nasal plugging for epistaxis ward, the hospital is required to motivate your continued • Nasal cautery accommodation in either of these facilities every 72 hours.
• You may be liable for a co-payment if your option stipulates • Removal of small hardware that you use a hospital network (except in an emergency), • Superficial foreign body removal and/or have not obtained pre-authorisation.
• Skin biopsy (subject to confirmatory histology results) – out- • In case of an emergency the Scheme must be notified within of-hospital benefit 48 hours or the first working day after treatment/admission.
An authorisation does not guarantee payment.
THE FOLLOWING ELECTIVE PROCEDURES WILL BE
FUNDED FROM IN-HOSPITAL BENEFITS IF PERFORMED
IN DOCTORS' ROOMS OR DAY CLINICS. IF THESE ARE
PRE-AUTHORISATION FOR DENTISTRY
PERFORMED IN HOSPITAL, THE MEMBER WILL BE LIABLE
FOR A CO-PAYMENT, UNLESS IN THE CASE OF AN
It is not necessary to obtain authorisation for routine EMERGENCY. IF THESE PROCEDURES ARE PERFORMED
procedures, e.g. fillings and extractions.
IN THE DOCTORS' ROOMS, THERE IS NO NEED FOR PRE-
AUTHORISATION.
Basic dentistry
• The Scheme must authorise dental procedures that require
• Arthroscopy – knee, shoulder • Procedures performed under general anaesthesia are only • Circumcision (children who are younger than 10 years) permitted for children under the age of seven years or in case of the surgical removal of impacted wisdom teeth.
• Colposcopy• D&C/evacuation • Endoscopy of the nose • All specialised dentistry services and procedures must be • Functional endoscopic sinus surgery • If any of the procedures involve hospitalisation, the member must obtain a pre-authorisation number via the Hospital Risk • Laparoscopy – diagnostic, sterilisation • Lithotripsy• Local excision of lump in breast (lumpectomy)• Meibomian cysts excision PRE-AUTHORISATION FOR PMB CHRONIC DISEASE LIST
• Minor perianal surgery • Myringotomy• Nasal cautery • The Disease Risk Management Programme's care plan • Nasal polypectomy will allow each registered beneficiary a certain number of consultations and investigations annually according to • Sigmoidoscopy • The beneficiary is notified about these benefits at the • Squint repair/strabismus beginning of each calendar year or shortly after being diagnosed with the condition.
• Thyroid cyst/nodule biopsy • No co-payment applies for the treatment of a PMB-CDL condition if you use the medicines in the MetRef formulary.
ANNEXURE F – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLAN
POLMED PREVENTATIVE HEALTHCARE BENEFITS 2012
POLMED has outlined services covered under preventative healthcare benefits. Best clinical practice dictates that the doctor should
follow best clinical management, as per the guidelines, even when it is not specified under this benefit.
All services specified in this schedule are to be covered from the in-hospital benefit.
TARIFF CODES
TARIFF CODES
Full annual medical
Osteoporosis screening (DEXA
scan, excluding sonar):
• Consultation; 0190-0192 (use in- Women over 65 years, once in a house code 5550 for submission of claims) See www.polmed.co.za • Cholesterol screening; All forms recommended by the for more information • Glucose screening; and National Department of Health • Healthy diet counselling Men between 50 and 75 years of 4524 Children under the age of 0022: Administration of 6 years in line with the National Department of Health schedule 88452: Immunisation at Well Baby Clinics • Beneficiaries between 40 and 99203: Preventative care: 64 years of age once every 3 Optometrist: 11202 (refer Immunisation, e.g. cost to Preferred Provider • Beneficiaries that are 65 and older once every year Hypothyroidism screening:
In newborn babies (younger
Flu vaccine:
Flu vaccine for all age groups Dental:
• Consultation, including
Hibtiter (specific antibody titer
oral hygiene instruction for children aged 6 years and Children age 5 years and • Oral hygiene instruction for Members aged 60 years and members between the ages of 7 and 18 years annually • Carries risk assessment for Only high-risk patients such Nappi: 836699 (Imovax babies up to children aged as those who are HIV positive, 14 years once every second have sickle cell disease (blood disorder) or splenectomy • Dental screening, including periodontal disease; carries risk assessment for beneficiaries over 19 years of Test – All age groups (ELISA age once every second year and Western blot; however, the Western blot: 3969 Western blot is only payable Cervical cancer screening (pap
after the ELISA test results were Women between 21 and 64 Counselling – All age groups 0016 (pre-counselling years of age once every three before and after testing annually 0017 (post counselling – Exclusion: Women who have had a complete hysterectomy with
no residual (remaining) cervix
Breast cancer screening
(mammogram):
• Women between 40 and 50
years of age once every 2 • Women between 51 and 70 years of age annually

Source: http://www.medicalbillingsolutions.co.za/files/2012%20Polmed%20Lower%20Plan.pdf