2017 No 10% Co-payment No waiting period No VAT International Student Health Plan Benefit Booklet
Contents 04 Value Add Benefits 4-5 ISS Health Plan Benefit 6 Managed Care Program 9 Additional Notes 10 05 09 P455 per month ONLY! To register for the International Student Health Plan, members are! required to provide proof of schooling i.e letter of admission. 2 IS HEALTH PLAN BENEFIT 2017 3
Value Add Benefits Severe Illness Benefit This benefit is designed to provide a 100% cash payout to the life assured on 1st diagnosis of any of the pre-defined severe illnesses regardless of the actual medical expenses incurred. The cash payout can be used among other things to: Value Add Benefits Screening and Prevention Benefit This benefit is designed to help members with prevention and early detection of certain illnesses/medical conditions. The benefit covers the following: a) Assist members with additional medical costs which might be above the allocated scheme limits b) Pay for alternative care or rehabilitation therapies not covered by the scheme c) Fund lifestyle changes that might be required following diagnosis and/or treatment of a severe illness. The following severe illnesses are covered under this benefit: Cancer Coronary Artery Bypass Graft Heart Attack Kidney Failure (Chronic) The benefit has a termination age of 65 years. T s & C s Apply Emergency Medical Services Bomaid has out-sourced this service from MRI Botswana (MRI). All Bomaid members can call MRI on 992 for emergency services throughout Botswana, Lesotho, Namibia, South Africa, Swaziland and Zimbabwe. Services offered: Major Organ Transplant (Kidney, Lung, Liver, Heart, Pancreas) Stroke Women s Health i) Pap smear for women aged 25-55 years once in two years. ii) Mammogram for women aged 40-70 years once in two years. Men s Health i) Prostate Specific Antigen (PSA) for men aged 40 years and above once in two years. Young Children and Aged Adults i) Flu vaccine once a year for members aged 10 years and below. ii) Flu vaccine once a year for members aged 65 years and above. iii) Flu vaccine one a year for vulnerable groups (e.g. members with certain and immunosuppression). Diabetes: i) Blood glucose test for members aged 35 years and above once a year. HIV/AIDS i) HIV rapid test for members aged 16 years and above once a year. ii) HIV Elisa test for members aged 16 years and above as a confirmatory test following a positive rapid test. iii) Post Exposure Prophylaxis for high risk groups (e.g healthcare personnel and rape victims). Glaucoma Screening i) Glaucoma screening test for members aged 40 years and above and high risk individuals (e.g. members with family history of glaucoma and members with diabetes). Remote medical advice & information Emergency medical assistance Emergency response to scene Pre hospital medical transportation Inter hospital transfer Upgrade transfer Downgrade transfer Medical repatriation Repatriation of mortal remains Emergency transportation of medical products Liaison with next of kin Escorted returns of minors In hospital medical monitoring Cardiac Diseases i) Blood cholesterol test for members aged 35 years and above once a year. Notes: Benefits available only where service is given by Bomaid approved service providers. Managed care, clinical protocols and scheme rules apply. 100% payout by scheme. Bomaid tariffs strictly apply. T s & C s Apply Dial OR +(267) 390 3066 for assistance. 4 IS HEALTH PLAN BENEFIT 2017 5
IS BENEFICIARY IS BENEFICIARY In-Hospital Benefits The services provided under this benefit include Consultations, Drugs, Investigations & Procedures. ** Where fixed fee arrangement has been entered into, those fees will apply Guaranteed ^ Cover on assessment *Preauthorisation required Day-to-Day Benefits Overall Scheme Benefit Limit Hospitalisation maximum * (daily maximum room rate at agreed tariff **) Professionals fees Doctors and Other Professionals Radiology Pathology Psychiatry ^ (in-patient cover in a recognised psychiatric facility, includes professional fees) Prosthesis ^ (external and internal) Sub-acute care (post admission step down - maximum 30 days) Laser refractive eye surgery * (referrals from approved Ophthalmologist/ Optometrist) Managed Care Benefits Chemotherapy, radiation therapy and brachytherapy ** (pre-authorisation required) Chronic medications (supplied through the managed care program in accordance with the Bomaid list of approved chronic conditions) Registration with the Bomaid managed care program required. ARV therapy (supplied through the managed care program) Registration with the Bomaid managed care program required. Outpatient Medical Care Consultations (General practitioners and Specialists) Procedures (medical/surgical) Diagnostic/Investigative Care Pathology Xray/Ultrasound MRI/CT scans Medications Doctor dispensed medications (for acute cases only) Over the counter medications Pharmacy dispensed medicine (includes dental & ophthalmic prescribed medications) Dental Care - Dental Overall Limit (subject to managed care protocols) In-patient dentistry * (the following sub-limits will apply) Hospital fees Dentist fees Anaesthetist fees 825,269 374,500 150,000 up to 150,000 up to 150,000 up to 150,000 40,000 30,000 13,600 4,500 130,000 36,000 12,000 6,520 2,070 4,450 10,800 2,000 1,800 7,000 5,200 750 200 3,750 48,249 22,000 12,000 5,500 4,500 **Preauthorisation required Refers to treatment every 2 years Level 1 and 2 conservative services and specialised services per specified dental protocols. Dentures limited to 1 plastic denture per 24 month cycle and are only available for members older than 21 years. Optical Care Appliances *Prescription required Allied Health Services Specialised dental treatment and oral surgery ** Simple maxillo-facial surgery: acute or chronic Orthodontic treatment (braces, retainers and related appliances) for members 26 years and below Out-patient dentistry (the following sub-limits will apply) Basic dentistry (includes consultations, radiology, filling, extraction, cleaning, scaling and polishingincision and drainage, root canal treatment) Specialised dentistry (includes crowns, bridges and dentures)** Orthodontic treatment (braces, retainers and related appliances) for members 26 years and above Designated Service Providers (managed care protocols apply) - comprehensive cover and reduced levels of copayment. Non-Designated Service Providers (managed care protocols apply) Consultation Clear aquity single vision lenses (per lens) Clear aquity bifocal a lenses (per lens) Clear aquity multifocal lens (per lens) Frame and/or any lens enhancements Contact lenses (only claimable as an alternative to frame and lenses) Appliances Overall Limit General appliances Medical appliances (including glucometers, nebulisers) Surgical appliances* (for non-permanent disability) ( to be recommended by surgeon/ orthopaedic surgeon) (includes knee/collar/chest/foot braces, crutches and walking frames) Wheel chairs, crutches and walking frames (for permanent disability) Hearing aid* (maximum 1 pair of appliances per 2 year cycle) Allied Health Services Rehabilitation Therapy Physiotherapy~ (motivational report needed for cases requiring more than 20 treatment sessions) Occupational therapy~ Speech therapy~ Clinical psychology~ 20,000 up to 20,000 up to 20,000 6,249 up to 6,249 up to 6,249 up to 6,249 130 500 750 1,200 900 2,500 9,000 4,500 700 700 up to 4,500 up to 9,000 7,506 6,506 3,253 3,253 3,253 6 IS HEALTH PLAN BENEFIT Medical referral needed 2017 7
IS BENEFICIARY Managed Care Program This is a program to help members with management of chronic ailments and includes benefit management & clinical advise. The following conditions are covered under this program: Safe Male Circumcision Severe Illness Benefit (Subject to Managed Care Protocols) Global Fee includes related costs of pre-operative testing & post-operative care within 1 month of procedure This benefit is designed to provide a 100% cash payout to the life assured on 1st diagnosis of any of the pre-defined severe illnesses regardless of the actual medical expenses incurred. 1,600 20,000 RESPIRATORY Asthma Allergic Rhinitis (only if associated with Asthma) Chronic Bronchitis Chronic Obstructive Pulmonary Disease ENDOCRINE NEUROLOGICAL & PSYCHIATRIC Epilepsy Parkison s Disease Migraine (Excludes acute attacks). Bipolar Disorder Chronic Anxiety Chronic Depression Schizophrenia Funeral Benefit This a benefit which comes at no additional cost to the member. 10,000 Diabetes Thyroid Dysfunction CARDIOVASCULAR Chronic Heart Diseases Hypertension RIP Funeral Benefit Top up T s & C s Apply Hospital Cash Plan T s & C s Apply The Bomaid Funeral Benefit Top Up is an optional benefit that allows the member to choose a cover that suits their needs. This cover is in addition to the basic funeral benefit the member already receives. This benefit can be purchased separately as an optional add-on to the existing benefit. This benefit pays out cash to members per night of hospitalisation. The benefit is voluntary and is purchased separately as an optional add-on to the existing benefit. The cash payout, amongst other things, can be used to meet members expense that may arise as result of being hospitalised. To process a pre-authorisation request, the following is required: For more information Bomaid www.bomaid.co.bw +267 3633100 For more information Bomaid www.bomaid.co.bw +267 3633100 RENAL Chronic Renal Failure Chronic Kidney Diseases OPTHALMIC Glaucoma INFECTIOUS DISEASES HIV / AIDS AUTOIMMUNE Multiple Sclerosis Psoriasis Systemic Lupus Erythematosus MUSCULOSKELETAL Arthritis Ankylosing Spondylitis Gout Osteopoenia Osteoporosis GASTROINTESTINAL & METABOLIC Inflammatory Bowel Disease Hypercholesterolaemia Peptic Ulcer Disease URINARY TRACT Benign Prostate Hypertrophy Letter of motivation from the service provider/doctor Detailed quotation Name of the patient Medical aid number Doctor s name and practice number Local: +(267) 3633 282 South Africa: +(27) 11 259 5115/5000 After Hours: +(267) 71 300 036 8 IS HEALTH PLAN BENEFIT Hospital name and practice number ICD10 codes (diagnoses codes) Itemised procedure codes Cost per procedure (add codes) Date of admission HIV/AIDS is a chronic condition managed under the HIV/AIDS Assistance Program. Assistance Provided by Bomaid is as follows: Cover for antiretroviral drugs Cover for laboratory monitoring tests Psychosocial support (counselling) including adherence counselling Cover for hospitalisation related to HIV/AIDS and/or opportunistic conditions Regular monitoring, evaluation and reporting Each individual enrolled on the program will be assisted with up to P12,600.00 per annum for ARV drugs & laboratory tests. ARV Drugs are provided through the Bomaid Managed Care Program only. Hospitalisation cover for HIV/AIDS related conditions is only available to members enrolled on the program. 2017 9
Additional Notes 1. In-patient and Managed Care Benefits: Pre-authorisation is required for all cases. Scheme and/or managed care protocols will be applied. Postadmission step down cover includes sub-acute care, hospice, private nursing and physical rehabilitation for approved clinical conditions. Excludes old age homes and frail care. Chronic medicines will be covered under the chronic medication benefit only if supplied through the Bomaid designated pharmacies. Any chronic medicines supplied outside the designated pharmacies will be covered under the pharmacy benefit. No cover for ARVs supplied outside the Bomaid designated pharmacies. 2. Medical/Surgical Out-patient Benefit: No cover for infertility treatment procedures. 3. Pharmaceutical Benefit Management Generic reference pricing (GRP) will apply to all schemes except Scheme C. Under the GRP, a brand-name medicine that has a generic equivalent registered in Botswana and available at the point of service will be reimbursed up to the tariff of the generic equivalent. Members will not pay the 10% co-payment should they opt to take the available generic medicines. Members will pay the difference between the tariff of the brand-name medicine and the generic equivalent should they opt to take the brand-name medicine while there is an available generic equivalent. 4. Dental Benefit: Maximum 2 preventative treatments per beneficiary per annum (e.g. cleaning, scaling and polishing). Re-treatment (e.g. filling) of a tooth within one year will be subjected to managed care and clinical protocols. Cover excludes: orthognatic (jaw correction) surgery, professionally applied fluoride, dental bleaching and implants. 10 IS HEALTH PLAN BENEFIT Pre-authorisation is required for all in hospital dental procedures as well as specialised dentistry (including orthodontic treatment, crowns, bridges and dentures). Pre-authorisation is NOT required for surgical procedures done under local anaesthesia in out-patient rooms. A two-year benefit cycle applies for specialised dentistry (including orthodontic treatment, crowns, bridges and dentures). 5. Optical Benefit: Reduced levels of member co-payments for services obtained from designated service providers. A two year benefit cycle applies (excludes consultations). 6. Appliances Benefit: One wheel chair per beneficiary over a 3 year cycle. One pair of hearing aids per beneficiary over a 2 year cycle. 7. Allied Health Services Benefit: Occupational therapy, speech therapy and clinical psychology benefits exclude therapy for social, educationaland developmental problems. Alternative treatment claim payments will only be made to members and not service providers. 8. Safe Male Circumcision: Cover includes pre-operative consultation/counselling, physical examination, HIV test and post-operative care within 1 month of operation. 9. Screening and Prevention Benefit: No pre-authorisation required. 100% payout of the scheme tariffs. Members liable for VAT where applicable. International Student Health Plan n n n No 10% Co-payment No waiting period No VAT
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