Articles

Membership


1. Important telephone numbers
Pre-Authorisation Tel Number:
0861 111 778
Evacuation and After Hours Emergency (Europ Assistance):
0861 112 162
Client Services:
0861 796 6400

Foundation Plan


1. Which hospitals can our members go to?
  • All hospitals networks are contracted and members can go to any hospital in which the preferred service provider works i.e. specialist or DSP GP
  • Note that involuntary admissions can go to any hospital; i.e. emergency cases can go to any hospital

2. Specialist benefit includes 4 visits to maximum of R1 000. Does this mean we only pay R250 per visit?
  • Each visit doesn’t have a set amount. The member has 4 visits available up to thecombined value of R1 000.
  • The member is required to make use of Agility Global Health Africa’s network specialists.
  • Specialist visits are also subject to pre-authorisation by the family doctor (GP), the contracted GP on the network will do this on behalf of the member. Preferred Specialists on this network are available on the website

3. Must the member inform the scheme of their nominated doctor?
  • No; there is no official doctor nomination process.
  • The first visit to the network doctor (GP) auto-nominates the doctor for that beneficiary
  • If the member wishes to move from the allocated doctor to another in the network, notification of this is required before the 1st of the next calendar month. This can be done via the RHMS contact centre (0861 796 6400).

4. Will the network GP refer patients only to Network specialists?
  • No they are not forced to , however the member needs to be informed that they might incur co-payments if the specialist is not one of our preferred providers
  • The network GP does have a list of our contracted specialists. The GP needs pre-authorisation for specialist referrals.

5. In relation to the Foundation Plan maternity benefit, the GP, Specialist and Midwife’s visits states the following: "subject to scheme protocols". How will these visits work?
  • Members have unlimited GP visits as per the day-to-day benefit,
  • Should the member need to see a specialist obstetrician then she will contact the scheme and motivate as to why this will be necessary, and obtain the required authorisation. A GP is more than capable of attending to a member during her pregnancy should there be no complications.
  • Should the member need to visit a specialist, funding will be done from the R1 000 Specialist allocation and furthermore be reimbursed according to PMB principles (i.e. pregnancy and its complications fall within this framework)

6. What is covered under the Guardian benefit stated as "Certain preventative tests covered at Network Providers"?
  • The Foundation formulary only provides for flu vaccines under this benefit as all other infant vaccines are catered for by the baby clinics as per Department of Health protocols. Vaccines other than those supplied by the DOH are not included.

7. Can you only make use of one allocated GP or can you go to various?
  • A beneficiary may choose to go to any network provider as this auto-nominates the provider for that beneficiary.
  • Doctor hopping is discouraged, however the beneficiary may elect to change within the network. Notification of this intent should be given before the 1st of the next calendar month to be able to seamlessly transfer within that month.
  • If movement takes place without prior notification, this visit to the new GP will be counted as an out of town visit and dealt with as such, i.e. the doctor will be paid at scheme rate and no acute medicines will be paid. The latter may be considered for reimbursement based on paper claims received. Note: PMB rules will apply.

8. How many out of network visits are available to our members and what will be covered under this benefit?
  • There are 3 out of network visits per family per year available to Foundation members.
  • These visits do not include cover for medication.
  • Kindly note that medication is only included if the GP is a dispensing GP and is willing to include acute medicine at scheme rate for the entire consultation. All other acute medication will be for the cost of the member; however if the medication is PMB related, then the scheme will refund the member.

9. Must the entire family visit the same GP?
  • Each beneficiary may go to another GP in another region as long as the GP forms part of the network,
  • E.g.: therefore the husband may visit a GP within the Gauteng network and the wife and children may visit a GP listed under the Polokwane network of providers.
  • The same principle of auto-nomination applies and the first visit elects the GP. Notification of change should be done before the 1st of the next month in which the beneficiary wishes to visit a new network provider. .

10. Radiology and pathology not mentioned in the Foundation Plan, what are they?
  • Resolution Health will only cover basic radiology and pathology as well as PMB’s; Note the network GP will request the appropriate radiology and pathology according to the list.
  • Additional imaging and pathology may be available on receipt of a motivation (PMB principles apply).

11. Non network hospital admission - Should a member be admitted to a private hospital not subject to our network hospitals and requires a scan for a stroke, what will happen? Do we cover PMB scans (MRI or CT) only at a provincial facility?
  • Only a few hospitals fall outside the 5 major hospital groups i.e. Netcare, NHN, Clinix, Mediclinic and LifeHealthcare (all hospitals in these groups are contracted). AGHSA has contracted with all these groups, however should a patient be admitted on an involuntary/emergency basis to a facility which is not contracted, the PMB principles apply and it is the managed care organisations prerogative to contact the said facility and negotiate tariffs or transfer the patient to a contracted hospital with due consideration to the gravity of the condition.
  • Special investigations will be dealt with similarly and would require authorisation to be obtained by the Specialist and hospital. The scheme will take the patient’s condition into consideration.
  • It is therefore possible that a MRI may be authorised in a non-contracted hospital for a non-contracted specialist in an emergency and it is also possible that a stable patient may be requested to transfer to a contracted facility.

Progressive Saver, Progressive Flex and Prestige Plans


1. Which hospitals can our members go to?
  • All hospitals. Preferred Service Providers are contracted with the scheme and members can go to any hospital in which the contacted service provider works i.e. specialist or GP
  • Note that involuntary admissions can go to any hospital; i.e. emergency cases can go to any hospital

2. Will the Agility network of providers be available on the website and when?
  • Yes, 1 January 2011
  • www.resomed.co.za

3. Who is on the AGHSA network for the Progressive - Saver, - Flex and the Prestige options?
  • AGHSA has contracted extensively with all major GP groupings across the country and has a list of more than 5 000 GP providers
  • The list will be available as from the 01 January 2011 on the website- www.resomed.co.za
  • Note that the GPs were contracted for all options excluding Foundation; that means that the contracts allow for all patients to see all preferred providers on all Progressive options as well as the Prestige option.
  • Note that patients have freedom of choice on the Progressive Flex and the Prestige option; however if they choose a clinician who has not contracted with the scheme they may be liable for a co-payment should the provider charge more than the scheme rate.

4. Will the Preferred Provider GP refer patients only to Preferred Provider Specialists?
  • A list of the Preferred Provider Specialists is available on the website – www.resomed.co.za.
  • Beneficiaries may be liable for co-payments should they opt to use a specialist outside the preferred provider list sand this provider charges higher fees than the scheme rates.
  • Specialists visits are described in the members handbook, and visits will be subtracted from this benefit with each visit irrespective of whether these are PMB visits or not (specific note for Prestige members.)

5. Radiology and Pathology list covered
  • Progressive Saver: a list of tests are available on the website and these tests will be reimbursed without authorisation for out of hospital visits (Specialist or GP); all other tests not listed need pre-authorization and PMB rules will apply; i.e. only PMB related tests will be authorised.
  • Progressive Flex and Prestige: pathology and radiology tests excluding specialised radiology will be reimbursed without prior authorisation; specialised radiology such as MRI and CT scans need authorisation. Note that where applicable PMB rules will apply.

6. Will acute medication be dispensed by the doctor?
  • Dispensing clinicians may dispense acute medicine to any patient on these option plans provided they adhere to the option specific formulary. In this case no co-payment (or short fall) will occur. The formularies for the various options are available on the website.
  • All chronic medication is subject to SOL authorisation by Medikredit irrespective of dispensing and prescribing.

7. Are there limits on the medications?
  • There are certain limits as per the Medikredit formulary and plan option on which the member is.
  • Reference pricing applies to all formularies and may result in co-payments should doctors prescribe more expensive brand names.
  • Progressive Saver members are subject to MMAP formularies, meaning that only generic medicines will be reimbursed according to the Medikredit MMAP formulary. Supply is limited to 10 days for acute medication. Longer use will require authorisation. Note that all Chronic MMAP products i.e. products that need chronic authorisation are excluded from this acute formulary.

8. Is Radiology and Pathology for the member’s own account when seeing a specialist?
  • Progressive Saver members: This is subject to a basket of tests and X-rays that are available to the Preferred Service Provider. Pre-authorisation will be needed to obtain imaging outside this basket and PMB principles will apply. Members will then also be notified if payment will be made by the scheme or by the member. It must be clinically relevant to the diagnosis and also done by the contracted providers where applicable.
  • Progressive Flex and Prestige options: Diagnostic tests will be reimbursed according to the member's handbook and specialised radiology requires pre-authorisation. Note that PMB principles will apply where applicable.

9. How do the acute medication work and which pharmacies can you visit if the doctor doesn’t dispense?
  • Progressive Saver: The Medikredit MMAP formulary will apply with a 10 day fill limit i.e. only generic medicines will be available without co-payment.
  • Progressive Flex and Prestige: Medikredit maintain formularies and reference pricing will apply across all formularies i.e. more expensive brand name products may incur co-payments.
  • Medikredit contracted pharmacies will charge scheme rates and will ensure that members don’t have to co-pay if formulary items are used.
  • Note that different options will have different formulary baskets which may affect the co-payment.

10. Professional fees in hospital are covered at the Network Provider rate. Will there then not be a co-payment?
  • No, as long as the member makes use of the Preferred Provider. Note that non-voluntary admissions to non Preferred Provider facilities will be reimbursed at scheme rates. If there is a difference, the member must submit the paper claim to the scheme for consideration of reimbursement (PMB principles and scheme rules apply).
  • Providers may join the Preferred Provider network by contracting with the AGHSA network at any time;
  • AGHS PPN Contact Centre @ 012 673 8600 or email This e-mail address is being protected from spambots. You need JavaScript enabled to view it. .

11. Can you only go to one allocated GP or can you go to various under the network?
  • You may change your provider at any time. Note however that “doctor hopping" is discouraged as this is not in the best interest of continuous care and it will be flagged on the system, GP hopping will be tracked.
  • One or two changes due to out of town visits are normal.

Hospital Plan


1. Where do you collect your chronic medication?
  • Medikredit pharmacy
  • Note that you need pre-authorisation on SOL for chronic medication.

Other


1. Which hospitals are we contracted with?
  • In order to allow Resolution Health members the widest choice possible, all hospital groups were contracted for 2011, these include: Life Healthcare, Netcare, Clinix, Mediclinic, and NHN groups.
  • Note the Provider, GP or Specialist, on the Preferred Provider list may influence your choice of a particular facility.

2. Psychiatric disorders – is it still 21 days for a PMB? Who is the network provider? Will DSMIV diagnostic criteria be accepted from a psychologist or should it be signed off by a psychiatrist? What happens if a psychiatrist is not available?
  • Yes, the 21 days are still approved for PMB conditions.
  • Preferred Provider lists are available but Progressive Flex and Prestige members may elect to use any provider cognizant of the fact that this may result in a co-payment should the provider charge more than the scheme rate.
  • DSM IV: This is a diagnostic tool to establish the different influences of co-morbidities on the patients primary diagnosis and will be accepted from a qualified clinician i.e. GP or Psychiatrist or Psychologist in order to obtain the benefit i.e. Medicine or admission based on the condition. PMB principles will however prevail as well as option specific benefits. Pre-authorisation is required for chronic medicine and hospitalization.

3. Haemodialysis – who is the Network Provider?
  • National Renal Care is the contracted Preferred Provider.
  • If other providers are used the reimbursed rate will be pegged against that of the Preferred Provider.

4. International travel cover –What is covered for 2011 and what is the process for an admission in case of an emergency abroad. How will the hospital admission and cost be covered?
  • I am waiting for confirmation on this form Resolution Underwriters

5. Orthodontics - Does the member pay the scheme money back should they resign while on a treatment plan?
Approved orthodontic plans are paid as follows: an initial deposit is payed to the provider and are continued with regular installments based on the duration of the therapy and frequency of the visits. Should a beneficiary resign from the scheme they become liable for the outstanding amount to the provider as the scheme will no longer fund the provider.

6. Are Chronic medications on all plan options obtainable from a Medikredit Pharmacy?
Yes

7. Will members receive new membership cards for 2011, Progressive members and Foundation members specifically?
Yes

8. Do the co-payments apply to the Foundation plan as well or only on the Progressive plans?
Co-payments are applicable under the following circumstances:
  • o As spelled out in the member booklet regarding in-hospital procedures
  • Medication dispensed outside the formulary or by a non contracted pharmacy where the product or the service fee is more than the contracted scheme rate
  • Consultations at non Preferred Providers where the provider charges more than scheme rates

9. Will Foundation and/or Progressive Flex cover a Glucometer for members registered on the chronic benefit for diabetes?
  • Glucometers will be given to all insulin dependent diabetics irrespective of the option
  • Non-insulin dependent diabetics will receive Glucometers if motivated by the clinician on SOL
    • Limited test strips are available as frequent monitoring is not essential in most cases; this may vary according to the option
    • 3 monthly HbA1c tests are however mandatory for all diabetics as to monitor their response to therapy
  • The Glucometer will be funded from external medical appliances (please note this is a PMB condition) and the actual strips needed for the Glucometer will be funded under the chronic benefit.

10. Co-Payments – what does “subject to Scheme Sub Limits" mean?
  • These sub-limits are subject to the specific procedure mentioned; however the co-payment is as stated

11. How is diabetes covered?
  • If the member does make use of insulin the strips, this will be paid, the only limit (on the number of strips) that exists on the strips is when you are a type 2 diabetic and not on insulin in which case the number is pegged per period. It is compulsory to get the HbA1c every three months as a diabetic and this is paid in full.
  • All chronic medications are subject to the Medikredit formulary and driven through compliance.

12. Cervical Cancer vaccination: For which vaccination will the scheme pay?
  • HPV vaccine is covered under the Guardian benefit for all options excluding the Foundation plan.

13. Pre-Authorisation on scans: When do you obtain authorisation? You have found out that sometimes you do not obtain authorisation for diagnostic scans but the doctor says they must do scan to do the diagnosis.
  • If the diagnosis is confirmed as a PMB, the member will be reimbursed for the scan. Note that pre-authorisation is required for all MRI, CT and PET Scans.

14. Dental - In-hospital procedures - Will we pay the dentist account according to the Scheme Rate out of risk, on the Prestige plan?
  • Only if pre-authorisation was obtained.
  • Kindly note that this does not apply to all dentists as they are not all specialists.
  • The scheme will not pay a general dentist the 220% fee for in-hospital treatment. If no pre-authorisation was obtained or if pre-authorisation was done too late, the account will be paid from the out-of-hospital benefit at the scheme rate. The scheme will pay the dentist subject to the use of Provider Networks at the contracted price. It is therefore imperative that member stays within the Preferred Provider Network if they do not want to risk co-payments.
  • Any provider (even the contract environment) will be paid up to the contracted scheme rate.

15. Who are the Preferred Providers for Dental and Optometry?
Agility has contracted with more than 1 300 dentists and 1 350 optometrists who will be available on the Resolution Health website (www.resomed.co.za).

16. What is the process for claims on Dental and Optometry?
  • The contracted provider can send the claim electronically to the scheme. If it is a provider outside the network, the member or provider will submit the claim electronically to the scheme and if there is no co-payment the claim will be settled. If the provider charges more than the network rate, there will be a portion payable by the member.
  • Scheme rates will only be paid on negotiated tariffs as per the Optometry tariff grid.

17. On Dental, how is authorisation obtained for impacted teeth?
The dental pre-authorisation line (0861 74 33 67) or dedicated e-mail address ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it. ) is used to request the authorisation.
  • X-rays and a doctors motivation needs to be submitted,
  • Approved procedures will be funded at scheme rates.
  • On the Hospital option, we will only pay the hospital and anaesthetist from the Risk benefit, the Dentist or Maxillo-Facial Specialist‘s account will be for the members own account.

18. Casualty fee – Please explain how this will be paid in 2011.
  • Hospital Casualty account A hospital casualty account may comprise of an outpatient facility fee, ward gasses and consumables, these services and respective fees are processed and paid subject to the casualty benefit. The approximate value can range between R500 and R 1000.
  • Attending Doctors’ account The attending doctors account comprises of a standard consultation charge and an emergency consultation charge to the approximate value of R340.00 which is processed and paid subject to the GP benefits. Injections and / or medication administered is processed and paid subject to the acute medication benefit.

19. HIV – can a member access the medications even if they don’t register on the HIV programme or is it subject to the programme?
Availability of medication through Careworks is subject to the member registering, otherwise the member will collect their medication from a provincial facility for the members cost as the programme is in place for the member to use.

20. HIV – which test do we cover for a HIV status test?
  • VCT (voluntary counseling and testing) is offered at contracted pharmacy and or doctors clinics where rapid tests are done.
  • Often rapid tests need confirmation and then the clinician may choose to draw blood and send this to a pathology laboratory, this will be paid from benefit.
  • Note that CD4 counts and viral loads outside of the CareWorks contract are not available on an out-patient basis.

21. Are only Progressive Saver and Foundation options subject to Medikredit pharmacies for medication?
  • All options are subject to Medikredit pharmacies should the member wish to avoid a possible co-payment.
  • Pharmacies charging higher than contracted fees may be used as long as the member understands that they now have the liability of a co-payment (if the fee is the same as the scheme rate then no co-payment is required).

22. Which pharmacies are Medikredit pharmacies?
A complete list available on the Medikredit website and includes pharmacies such as Dischem, Clicks, and most smaller pharmacies etc.

23. Oncology Provider Networks?
  • Foundation, Hospital and the Progressive Saver options are restricted to the providers and protocols supplied by the ICON network as spelled out in the member handbook.
  • Progressive Flex and Prestige option members are advised to utilise the AGHS provider network and protocols in order to avoid possible co-payments should a non-contracted provider request non-protocol therapy or levy higher fees.
    • AGHSA has contracted 95% of all oncologist in SA,
    • Protocols are endorsed by the oncologists and include biologicals such as Mabthera® and Trastuzumab (Herceptin®) when a patient qualifies for such,
    • Note the benefit is unlimited within the framework of the protocol entitlement.

Important Telephone numbers


1. Pre-Authorisation Tel Number:

0861 111 778


2. Evacuation and after-hours Emergency:

0861 112 162


3. 24 Hour HIV/AIDS Helpline: CareWorks

0860 10 1110


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