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The Mumed Option
Overview
The Mumed option is an affordable plan with traditional
benefits combined with a medical savings account for
young members and families who want the freedom
to see a healthcare provider of choice when necessary.
YOU CAN LOOK FORWARD TO THE ESSENTIAL COVER AND BENEFITS YOU TRULY NEED FROM
MUMED IN 2012
- Day-to-day benefits of up to R10 450 per family per annum
- You receive
unlimited
cover for basic dentistry
- We provide cover for professional sportsmen and
women, for injuries relating to participation in
professional sport
- You receive cover for 27 chronic conditions
- We offer a benefit for oral contraceptives from risk
- You now have a basket of wellness benefits - including
preventative screening for blood pressure, glucose,
cholesterol, BMI and waist circumference, certain baby
immunisations, flu vaccinations, HPV (cervical cancer)
vaccination, adult pneumococcal vaccination, pap smears,
prostate specific antigen test, VCT test, baby wellness
visits and malaria prophylaxis paid from risk, subject
to protocols
- You pay only for the first three child
dependants – the rest are free!
Day-to-Day Benefits
Day-to-day claims are initially paid from the annual Medical Savings
Account (MSA) and thereafter from the Annual Flexi Benefit (AFB). Once
the MSA and AFB have been depleted, basic dentistry will be unlimited
for the remainder of the year.
Total annual Medical Savings Account and Annual Flexi Benefit
P – Principal member A – Adult dependant
C – Child dependant
| MUMED |
Annual Flexi Benefit |
| P |
R4 400 |
| P + A |
R7 150 |
| P + A + C |
R8 250 |
| P + A + 2C |
R9 350 |
| P + A + 3C |
R10 450 |
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Day-to-Day Benefits
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Medical Savings
Account |
Annual Flexi Benefit |
Total Day-to-Day Benefit |
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Member |
R2 196 |
R2 204 |
R4 400 |
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Adult Dependant |
R1 380 |
R1 370 |
R2 750 |
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Child Dependant |
R552 |
R548 |
R1 100 |
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Day-to-day services are initially paid from the Medical Savings Account (MSA) and thereafter from the
Annual Flexi Benefit (AFB)
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BENEFITS
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LIMITS
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GP consultations
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Visits are limited to: M: 6 visits; M1: 8 visits; M2: 10 visits; M3+: 11 visits
– initially paid from the MSA and AFB, thereafter the balance of the visits are available
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Specialist consultations
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Paid from the MSA and AFB |
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Acute Medicine (25% co-payment on all medicine without a generic equivalent)
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Paid from the MSA and AFB, subject to formulary and MRP |
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Over-the-counter medicine (including schedule 0,1 and 2 medicines) and Homeopathic
medicines
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Paid from the MSA and AFB, subject to formulary and MRP, limited to R440 p/b and
R770 p/f (limited to one script per day and a maximum of R130 per event) |
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Basic Radiology
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Paid from the MSA and AFB |
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Basic Pathology
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Paid from the MSA and AFB |
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Basic dentistry
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Initially paid from the MSA and AFB, thereafter unlimited |
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Specialised Dentistry
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Paid from the MSA and AFB, limited to R1 430 p/b, subject to protocols |
Optometry
Visits
Lenses,
frames and contact lenses
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Paid from the MSA and AFB
1 visit p/b per annum
Limited to R1 100 p/b and R3 190 p/f
per annum (subject to protocols)
Frame sub-limit included in lens limit R550 p/b
per annum |
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Auxiliary services
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Paid from the MSA and AFB, collective limit of R1 375 p/b and R2 200 p/f |
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Clinical psychology
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Paid from the MSA and AFB, limited to R1 155 p/f, subject to protocols |
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Psychiatry
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Paid from the MSA and AFB, limited to R2 900 p/f, subject to protocols |
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Home Oxygen Ventilation
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Paid from the MSA and AFB, subject to pre-authorisation, PMBs and protocols |
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Private nursing at home
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100% GWR, paid from the MSA and AFB, limited to 20 days, subject to protocols
and pre-authorisation |
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Ante-natal classes
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Paid from the MSA and AFB, limited to R550 |
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Hospital emergency room/casualty emergency visits (not requiring admissions excluding
facility fees)
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Paid from the MSA and AFB |
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Day-to-day services not subject to MSA or AFB,
paid from risk
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BENEFITS
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LIMITS
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Surgical and medical appliances
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100% of cost, limited to R5 775 p/f, sub-limits apply –
click here for details |
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Emergency road-side assistance and ambulance transportation
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Unlimited, preferred provider |
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Wellness, lifestyle and preventative care benefits paid from risk
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Benefits
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Limits
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Women's Health |
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Cervical Cancer Vaccine |
1 course (3 doses per registered schedule), once-off for female beneficiaries
between the ages of 12 and 18 years |
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Pap smear |
1 test per year per female beneficiary over the age of 18 years |
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Oral contraceptives |
Limited to R100 p/b per month |
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Men’s health |
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Prostate specific antigen |
1 test annually per male beneficiary over the age of 40 years |
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Children’s health |
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Baby wellness visits |
2 visits per annum for children between 4 weeks and 18 months at DSP |
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Vaccinations |
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Flu vaccine |
1 p/b per year, limited to R70 |
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Tetanus diphtheria injection |
As required |
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Pneumococcal vaccine |
As required, p/b over 60 years of age and high risk members, subject to
pre-authorisation |
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Prophylaxis (malaria) |
As required |
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Lifestyle |
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Universal 360° check including cholesterol, glucose, blood pressure, BMI, waist
circumference, exercise plan and meal plan |
1 per year p/b over the age of 18 years, limited to R100 p/b at DSP |
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Smoking cessation programme |
Once a lifetime p/b Limited to R2 500 Conditions apply |
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VCT and HIV |
Once a year p/b |
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Cover for Chronic Conditions
The Mumed option offers extensive cover for 27 chronic conditions as per
the Chronic Disease List (CDL) conditions.
If you suffer from one of the chronic conditions on the list, you need to
register with Mediscor in order to qualify for the chronic benefit.
Chronic medication is subject to the basic formulary and Mediscor
Reference Pricing. A 25% co-payment is payable for the voluntary use of
non-formulary or non-generic medicines.
All registered CDL chronic medication is unlimited and not subject to the
MSA and AFB.
In-hospital Benefits
| BENEFIT
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LIMITS
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Overall Annual Limit (OAL)
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PMBs unlimited R550 000 p/b and R1.1 million p/f for non-PMBs
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Private hospitals and nursing homes
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100% of AT, subject to OAL, subject to pre-authorisation
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Ward fees: General; High Care; Intensive Care
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100% of AT, subject to OAL
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Theatre fees
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100% of AT, subject to OAL
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TTO medication (take home medication)
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Limited to 7 days supply
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GPs and specialists
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Subject to OAL, 100% of AT
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Surgical prosthesis and electronic/nuclear devices
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Subject to OAL, limits per category, sub-limits apply, subject to pre-authorisation
and protocols
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Radiology
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100% of Agreed Tariff, limited to R22 000 p/f Subject to OAL
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Pathology
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100% of Agreed Tariff, limited to R16
500 p/f Subject to OAL
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MRI, CT scans and PET scans (Combined in and out of hospital benefit)
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Subject to OAL, 100% of AT, limited to R11 000 p/f, pre-authorisation required
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Physiotherapy in hospital
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Subject to OAL, 100% of AT, limited to R4 400 p/f
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Organ transplants, renal dialysis (includes transportation of the organ, surgically
related procedures, professional fees and services, as well as immunosuppressant
drugs)
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Subject to OAL, 100% of AT, PMBs only, subject to pre-authorisation, protocols,
and DSP
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Sport injuries
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Subject to OAL, 100% of AT, including professional sport
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Emergency room/casualty
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Subject to OAL, 100% of AT, for emergency medical treatment for injuries resulting
from accidents or trauma
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Alternatives to Hospitalisation
The Mumed option offers cover for step-down nursing facilities, Hospice and rehabilitation.
Cover is subject to pre-authorisation, protocols and case management, and OAL.
Prescribed Minimum Benefits (PMB)
- Subject to Scheme protocols
- Hospitalisation –
100% of cost at DSP, unlimited
- Medication
– CDL conditions are unlimited subject to a formulary and dispensed by a DSP
- Medical
management in and out of hospital – 100% AT, subject to protocols and treatment
by DSP
- HIV/AIDS – subject to registration on HIV/AIDS programme, subject to protocols,
failing which a R3 000 limit will apply
Co-Payments for in-Hospital Procedures
Co-payments are payable on specified elective procedures (excluding
PMBs) done in a hospital or a day facility. The following treatments
require a R1 500 co-payment:
Gastroscopy, colonoscopy, cystoscopy, nasal/sinus endoscopy, functional
nasal surgery (septoplasty), hysteroscopy, flexible sigmoidoscopy, arthroscopy,
diagnostic laparoscopy, dental, conservative back and neck treatment (spinal
cord injections)
The following treatment requires a R1 000 co-payment:
Excision lesion (benign & malignant)
The following treatments require a R8 000 co-payment:
Joint replacements (arthroplasty), laminectomy and spinal fusion and
Nissen fundoplication (reflux surgery)
The following treatment requires a R3 000 co-payment:
Hysterectomy (except for cancer)
Contributions Table
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Salary (Rand)
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Principal
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Adult
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Child
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0 - 6
000
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R1 242 |
R966 |
R354 |
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6 001 - 7 900 |
R1 380 |
R1 074 |
R390 |
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7 901 - 15 000 |
R1 506 |
R1 176 |
R426 |
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15 000+ |
R1 674 |
R1 306 |
R468 |
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Glossary
- PMB - Prescribed Minimum Benefit
- P/B - Per
Beneficiary
- AFB - Annual Flexi Benefit
- P/F - Per Family
- CDL - Chronic Disease List
- AT
- Agreed Tariff
- OAL - Overall Annual Limit
- MSA Medical Savings Account
- DSP - Designated Service Provider
- MRP - Mediscor Reference Pricing
- GWR - General Ward Rate
- TTO - To Take Out i.e. Medicines taken out of hospital when discharged
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