nimas heartbeat 2012 - memp€¦ · nimas heartbeat 2012 10/17/11 16:26 page 1 composite c m y cm...

Nimas Heartbeat 2012 10/17/11 16:26

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C M Y CM MY CY CMY K

THE HEARTBEAT

IN THIS ISSUE

Message from the PrincipalOfficer

Step-by-step guide tochoosing your 2012 benefitoption

Making your selection

A brief explanation of thebenefit options for 2012

Benefit schedules

Contributions

Designated providers

Preventative benefits

Deductibles on procedures

Wellness programme

October 2011

Welcome to this special edition of TheHeartbeat wherein the structure of theNIMAS benefit options for 2012 isprovided and details of all options areincluded. Please keep this newsletter ina safe place as you may need to referto it at various times during 2012.

We continually strive to provide you withmore benefit for your Rand and are pleasedto inform you that all benefits haveincreased across all options.

As an additional benefit and at no extra costto you, we have launched a wellnessprogramme, which is available to all NIMASmembers. Information about the rewardsand discounts available to you are provided

on page 15. We are confident that thewellness programme will add further valueto you. From the favourable responsesreceived from members thus far, it is awelcomed addition.

Contributions have increased per option asfollows: 9.47% for the Core Option, 9.52%for the Classic Option, 11.58% for theMillennium Option and 9.25% for theSupreme Option.

You can use the step-by-step guide on pages2 to 3 and the benefit option-specificinformation to select your option for 2012.If you are changing your option for 2012,please return the Option Selection Form toNIMAS. Alternatively, you may choose to

use one of the other member-friendly

methods that NIMAS has implemented to

notify us of your option change; for example,

by SMS reply. Full details are included on

page 4 of this edition. Remember, whichever

method you select, your response must

reach NIMAS by 1 December 2011.

NIMAS remains among the more

competitive medical schemes with one of

the best benefit per Rand offerings on the

market.

Regards,

Sam McGuigan


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1. The Core, Classic, Millennium and Supreme options all provideunlimited hospitalisation.

2. Members on the Supreme Option are not required to pay deductibleson procedures, but members on the Core, Classic and Millenniumoptions will have to pay a deductible for certain hospital procedures.The deductibles differ per procedure and are higher on the Core andClassic options than on the Millennium Option.

3. The benefits for prosthesis, appliances, radiology and oncology arehighest on the Supreme Option, followed by the Millennium andthen the Classic and Core options.

1. When selecting your option, choose an option that covers yourchronic condition.

2. If you are on the Core, Classic and Millennium options, yourchronic medication must be obtained from designated pharmacies.If a non-designated pharmacy is used, levies/deductibles mayapply. If you are on the Supreme Option, your chronic medicationmay be obtained from Atlas, Clicks, Dis-Chem and Sparkportpharmacies. You have a choice to either use the courier servicethat these pharmacies offer or to visit a branch nearest to you.Should a non-designated pharmacy be used, levies/deductiblesmay apply.

1

2

3

In-hospitalcover

Deductibles onprocedures

Major medicalexpenses

Ca

Please feel free to contact the NIMAS call centre on 0860 646 272 should you r

STEP-BY-STEP GUIDE TO CHOOSING YOUR 2012

Hospital and major medical expenses Chronic medication

Benefitoptions

Core

Unlimited hospitalisation.In-hospital service providerspaid at 100% of NIMAS rate.

Higher deductibles on in-hospitalprocedures.

Lower prosthesis, appliance, radiologyand oncology benefits.

Cfp

Classic


Higher deductibles on certain in- and out-of-hospital procedures.

Lower prosthesis, appliance, radiologyand oncology benefits.

Cfp

Millennium


Relatively low deductibles oncertain in- and out-of-hospitalprocedures.

High prosthesis, appliance, radiology andoncology benefits.

Cort

Supreme

Unlimited hospitalisation. Mostin-hospital service providerspaid at 150% of NIMAS rate.

No deductibles on procedures. Comprehensive prosthesis, appliance,radiology and oncology benefits.

CohoCD

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1. The Core Option provides no day-to-day benefits. The Classic, Millennium and Supreme optionswork on a 'fee-for-service' arrangement whereby members select a provider of their own choice.Each time the provider charges you, the Scheme will deduct the amount from your benefitlimits or savings. On the Classic and Millennium options, acute medication must be obtainedfrom designated pharmacies. If a non-designated pharmacy is used, levies/deductibles mayapply.

2. Do you prefer your day-to-day benefits to be paid from a medical savings account or a traditionalbenefit limit? In the case of the Millennium Option, day-to-day benefits are paid from a medicalsavings account or above threshold benefit. Members with medical savings accounts retainany savings remaining in their medical savings accounts once their day-to-day expenses havebeen paid. On the Supreme and Classic options day-to-day benefits are paid from the variousbenefit limits.

3. How much are the benefit limits? The Supreme Option provides high day-to-day benefits, withparticularly high sub-limits in the areas of basic and advanced dentistry, acute medication andauxiliary services. The Classic Option has adequate but lower day-to-day benefits. Benefits onthe Millennium Option are determined by the extent of the member's medical savings account,the above threshold benefit and certain benefit sub-limits.

The cost of the benefit option is always animportant factor in determining choice. Donot, however, select a benefit option basedon price alone as you may find that the benefitsare inadequate to meet your and your family'sneeds. Refer to 'Contributions' on page 13 forthe corresponding contribution.

Conditions covered andapplicable formulary

Fee for service orcapitation Savings/limits

ou require any further assistance in selecting a benefit option for 2012.

Cost

2 BENEFIT OPTION

Day-to-day services Contributions

Cover for 26 CDL PMB conditions. Riskformulary. Subject to designatedpharmacies.

Fee for service and free choice ofprovider at designated hospitals.Chronic medication must be obtainedfrom designated pharmacies.

No benefit unless PMB-related. Refer to contributiontables.

Cover for 26 CDL PMB conditions. Riskformulary. Subject to designatedpharmacies.

Fee for service and free choice ofprovider at designated hospitals.Chronic and acute medication mustbe obtained from designatedpharmacies.

Paid from benefit limits. Lowerbenefit limits.

Refer to contributiontables.

Cover for 26 CDL PMB conditions, plusosteoporosis, gout, gastro oesophagealreflux disease. Risk formulary. Subjectto designated pharmacies.

Fee for service and free choice ofprovider at designated hospitals.Chronic and acute medication mustbe obtained from designatedpharmacies.

Paid from medical savingsaccount. Determined by extentof medical savings account,above threshold benefit andbenefit sub-limits.


Cover for 26 CDL PMB conditions, plusosteoporosis, gout, benign prostatichypertrophy, psoriasis and gastrooesophageal reflux disease.Comprehensive formulary. Atlas, Clicks,Dis-Chem and Sparkport pharmacies.

Fee for service and free choice ofprovider at designated hospitals.Chronic and acute medication mustbe obtained from Atlas, Clicks, Dis-Chem and Sparkport pharmacies.

Paid from benefit limits. Highbenefit limits.


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You need to inform

NIMAS of your benefit

option selection in any

of the following ways

(members of registered

employer groups

should submit their

Option Selection Form

to their employer)

Making your selection

Page 4

Telephonic

Contact our Client Services Department on 0860 646 272, listen tothe voice prompts and follow the instructions carefully.

Post

Enclosed you will find an Option Selection Form. Please post yourcompleted form to NIMAS, PO Box 1000, Westville 3630.

Fax

Fax your completed Option Selection Form to 0861 888 822.

Web/internet

Update your benefit option selection online at www.nimas.co.za.

SMS

Wait for our target SMS and reply to the SMS you received to selectyour benefit option.

E-mail

Wait for our target e-mail and follow the link to the website to selectyour benefit option.

Hand delivery

You may hand deliver your completed Option Selection Form to:NIMAS1 Canegate RoadLa Lucia RidgeUmhlanga Rocks

Please note

Is there a deadline for the submission of yourbenefit option selection?

You must inform NIMAS of your new benefit optionselection by Thursday 1 December 2011.

Will NIMAS allow you to change your benefit optionagain?

Members may only change their benefit option atthe end of each year for the following year, and willnot be allowed to change benefit options during theyear.

If you do not want to change benefit options for2012 you do not have to inform NIMAS. If we donot receive your option selection by Thursday1 December 2011, you will remain on your currentbenefit option.


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Important components of your option

Risk benefits

Major hospital expenses are covered underrisk benefits, which are divided between in-hospital and certain out-of-hospital benefits.

In-hospital benefits

Major medical expenses, e.g. hospitalisation,general wards, intensive care unit (ICU),theatre procedures, radiology and pathology,are covered under risk benefits at 100%of the NIMAS rate. Certain sub-limits apply.

Benefits are provided at designatedhospitals. In the event of voluntaryadmission to a non-designated hospital,benefits will be paid to a maximum of 75%of the NIMAS rate. Details of designatedhospitals can be viewed at www.nimas.co.zaor contact NIMAS on 0860 646 272.A deductible applies for certain specifichigh-cost in-hospital procedures unless thehospital service was obtained involuntarily,for example, in the case of a life-threateningemergency. See 'Deductibles on procedures'on page 14.

Out-of-hospital benefits

Certain out-of-hospital procedures are paidfrom risk benefits. The benefit schedule onpages 9 to 12 will provide you with moreinformation on the specific procedures.All procedures performed out of hospitalwill attract a deductible. Please refer to'Deductibles on procedures' on page 14.

Remember: The Core Option is ahospital option, which means thatday-to-day and dental benefits arenot covered.

A brief explanation of the benefit options for 2012Please refer to 'Benefit schedules' on pages 9 to 12 for further details.

C O R E O P T I O N

The Core Option is a hospital option that provides hospital benefits for members who are looking forwell-balanced hospital cover.

C L A S S I C O P T I O N

The Classic Option is a traditional benefit-based option that provides benefits for members who arelooking for well-balanced risk cover and appropriate day-to-day benefits.


1. Risk benefits

Major hospital expenses are coveredunder risk benefits, which are dividedbetween in-hospital and certain out-of-hospital benefits.


Major medical expenses, e.g. hospitalisation,general wards, intensive care unit (ICU),theatre procedures, radiology and pathology,have unlimited cover under risk benefitsat 100% of the NIMAS rate. Certain sub-limits apply.

Benefits for hospitalisation are providedat designated hospitals. In the event of

voluntary admission to a non-designatedhospital, benefits will be paid to a maximumof 75% of the NIMAS rate. Details of thedesignated hospitals can be viewed atwww.nimas.co.za or contact NIMAS on0860 646 272.

A deductible applies for certain specifichigh-cost in-hospital procedures unless thehospital service was obtained involuntarilyfor example, in the case of a life-threateningemergency. See 'Deductibles on procedures'on page 14.


Certain out-of-hospital procedures are paidfrom risk benefits. The benefit schedule onpages 9 to 12 will provide you with more

information on the specific procedures.A small number of procedures performedout of hospital will attract a deductible.Please refer to 'Deductibles on procedures'on page 14.

2. Day-to-day cover

All day-to-day medical expenses, e.g. GPand specialist consultations and acutemedication, are paid from this benefit.Optometry is paid from a separate benefit.

Remember: All dental services,including dental expenses incurredin hospital, are paid from yourout-of-hospital benefit up tothe basic or advanced dentistrysub-limits.

M I L L E N N I U M O P T I O N

The Millennium Option is a new generation option that combines the flexibility of a medical savingsplan with an above threshold benefit when your day-to-day expenses are particularly high. Members arerewarded for low claims by retaining any unused medical savings. Hospital and chronic medicationbenefits are also comprehensive.

A simple guide to the MillenniumOptionDay-to-day claims are treated separatelyfrom hospital, hospital-associated andchronic medication claims.

Day-to-day claims

1. All members are given a separate medicalsavings account at the beginning of thebenefit year. All day-to-day claims arepaid from the medical savings account.

2. The money in the medical savings accountbelongs to you. If you do not use all themoney in your medical savings account,the money is retained in your account andcarried over to the following benefit year.

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1. Risk benefits

Major hospital expenses are covered underrisk benefits, which are divided betweenin-hospital and certain out-of-hospitalbenefits. Risk benefits are not paid fromeither the medical savings account orthe above threshold benefit and do notcontribute to the threshold level.


Major medical expenses, e.g. hospitalisation,general wards, intensive care unit (ICU),theatre procedures, radiology and pathology,have unlimited cover under risk benefitsat 100% of the NIMAS rate. Certain sub-limits apply.

Benefits for hospitalisation are providedat designated hospitals. In the event ofvoluntary admission to a non-designatedhospital, benefits will be paid to a maximumof 75% of the NIMAS rate. Details of thedesignated hospitals can be viewed atwww.nimas.co.za or contact NIMAS on0860 646 272.

A deductible applies for certain specific high-cost in-hospital procedures unless the

hospital service was obtained involuntarily,for example, in the case of a life-threateningemergency. See 'Deductibles on procedures'on page 14.


Certain out-of-hospital procedures are paidfrom risk benefits. The benefit schedulesprovide you with more information on thespecific procedures. A small number ofprocedures performed out of hospital willattract a deductible. Please refer to'Deductibles on procedures' on page 14.

2. Medical savings account

A portion of your monthly contribution isallocated to a medical savings account fromwhich day-to-day medical expenses are paid.Your full benefit year's medical savings(12 x the medical savings portion of themonthly contribution) is available from1 January 2012. You may decide how tospend your savings on various day-to-daymedical expenses, e.g. medication, dentistryand GP consultations. Members arerewarded for lower day-to-day claims. If amember has any medical savings left at theend of the benefit year, these will be carriedover to his/her medical savings account forthe following benefit year.

Warning: Your day-to-day expensesare paid at the actual amountcharged by your service provider,so if your provider charges morethan the NIMAS rate, your medicalsavings account will be depletedfaster.

Warning: If a member uses allhis/her medical savings and thenresigns from NIMAS during thebenefit year, the member willremain liable for payment of thebalance of the medical savingscontribution for the remainder ofthe benefit year.

Tip: Optometry is not paid fromyour medical savings or the abovethreshold benefit but from aseparate benefit. Optical expensesexceeding the optometry benefitmay be paid from the medicalsavings account but will notaccumulate to the threshold level.

Remember: All dental services,including dental expenses incurredin hospital, are paid from yourmedical savings or the abovethreshold benefit up to the basicor advanced dentistry sub-limits.

MILLENNIUM OPTION IN MORE DETAIL

Medicalsavingsaccount

Self-paymentgap

Climber A has medical savings available to pay for day-to-daymedical expenses. If he does not use all his medical savingsduring the benefit year, the remaining medical savings will carryover to the following year.

Climber B has used up all his funds in his medical savings accountto pay for day-to-day medical expenses. As his expenses have notyet reached the threshold level (when the above threshold benefitbecomes available), he will have to pay for his expenses himselfuntil he reaches the threshold level.

Climber C's day-to-day medical expenses have been very high forthis benefit year. He has utilised all his medical savings and hadto pay for his day-to-day expenses himself once he exhausted hismedical savings account until he reached the threshold level.Now that he has reached this level he will have relief as his day-to-day expenses will be paid from the above threshold benefituntil the above threshold benefit limit is reached.

Abovethreshold

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This process is illustrated below:

3. When your day-to-day claims exceed acertain level known as a 'threshold level',your claims are then paid from the abovethreshold benefit and not from yourmedical savings account. You thus haverelief for those years where your day-to-day medical expenses are very high.

4. The threshold level (the level at which theabove threshold benefit becomes availableto you) is higher than the amount availablein your medical savings account. Thismeans that if you exhaust your medicalsavings account you will have to pay foryour day-to-day expenses yourself untilthe level is reached where the abovethreshold benefit becomes available.

Hospital, hospital-associated and chronicmedication claims

Major hospital expenses and certain out-of-hospital benefits are paid from riskbenefits. Chronic medication is paid froma separate benefit.


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Getting to the threshold level (and therebygaining access to the above thresholdbenefit)

As we pay your day-to-day expenses fromyour medical savings account and evenwhen your medical savings account isdepleted, we add up your day-to-dayexpenses at the NIMAS rate until you reachthe threshold level at which point the abovethreshold benefit comes into effect.

What expenses will the member be liablefor?

The threshold level (level at which the abovethreshold benefit becomes available) ishigher than your medical savings account(unless a member has medical savingscarried over from the previous benefit year).

Below follows an explanation of what weconsider when reaching the thresholdlevel:

This means that if you exhaust your medicalsavings, you will have to pay day-to-dayexpenses yourself until you reach thethreshold level. This stage is known as the'self-payment gap'. Once the threshold levelis reached you will have access to the abovethreshold benefit.

Remember: Even when you are inthe self-payment gap you muststill submit all your claims toNIMAS, even if you settle itdirectly with the service provider.This will allow us to process theclaim so that the benefit can addup to the threshold level.

Warning: Your day-to-day benefitswill be paid from your medicalsavings account at the amountcharged by your provider and notat the NIMAS rate. We will,however, add up these expensesto reach the threshold level at theNIMAS rate. If your provider has

charged an amount exceeding theNIMAS rate, you will not reachthe threshold level as quickly, thustaking longer to obtain access tothe above threshold benefit.

Tip: You can reduce the extent ofthe self-payment gap by utilisingservice providers who charge theNIMAS rate. This will mean thatyour expenses will be paid atthe same rate at which theyaccumulate to the thresholdlevel and your medical savingswill last longer.

How do the sub-limits work?

There are sub-limits for acute and over-the-counter (OTC) medication, basic andadvanced dentistry and auxiliary services.The sub-limits apply across the medicalsavings account, the self-payment gapand the above threshold benefit. This meansthat the maximum that can be spent on aparticular benefit is limited to the sub-limit.

Member R5 400 R8 080 R3 980

Adult dependant R4 320 R6 470 R3 400

Child dependant R1 188 (first three R1 800 (per child) R560 (per child)children only)

Annual savings Threshold level Above threshold benefit

The threshold level and the above threshold benefit:

Expense Taken into account? Notes

2012 day-to-day claims Yes

2011 day-to-day claims No

Hospital and hospital-related expenses No

Chronic medication No

General practitioner (GP) and specialist consultations Yes

Acute and over-the-counter (OTC) and to-take-out (TTO) medication Yes Subject to sub-limits.

Basic dentistry Yes Subject to sub-limits.

Advanced dentistry Yes Subject to sub-limits.

Radiology and pathology (excluding advanced radiology) Yes

Auxiliary services (physiotherapy, homeopathy, chiropractic services,speech/occupational therapy and clinical psychology)

Yes Subject to sub-limits.

Optometry No Separate limit, which is not paidfrom medical savings or abovethreshold benefit.

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3. The above threshold benefit

What is the above threshold benefit?

The above threshold benefit provides relieffor members when their day-to-day medicalexpenses are very high. We add up your day-to-day expenses until they reach a certainlevel or 'threshold level'. Once this level is

reached, you have access to the abovethreshold benefit.

All further day-to-day medical expenses willthen be paid from this benefit at the NIMASrate and not from your medical savingsaccount or your own pocket, unless theservice provider charges in excess of theNIMAS rate.

Remember: If you deplete theabove threshold benefit, youwill need to pay for furtherday-to-day expenses, unlessyou still have a positive balancein your medical savings accountwhich will then be used to coverfurther claims.


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S U P R E M E O P T I O N

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The Supreme Option provides comprehensive benefits and is designed for members looking for maximumcover and generous day-to-day benefits.


1. Risk benefits

Major hospital expenses are covered underrisk benefits, which are divided betweenin-hospital and certain out-of-hospitalbenefits.


Major medical expenses, e.g. hospitalisation,general wards, intensive care unit (ICU),theatre procedures, radiology and pathology,have unlimited cover under risk benefits.The services of certain in-hospital providerssuch as surgeons, anaesthetists and ad-mitting practitioners are paid at 150% ofthe NIMAS rate. Certain sub-limits apply.

There are no deductibles on procedurespayable by Supreme members.

Benefits for hospitalisation are providedat designated hospitals. In the event ofvoluntary admission to a non-designatedhospital, benefits will be paid to a maximumof 75% of the NIMAS rate. Details of thedesignated hospitals can be viewed atwww.nimas.co.za or contact NIMAS on0860 646 272.


Certain out-of-hospital procedures are paidfrom risk benefits. The benefits table willprovide you with more information on thespecific procedures.

2. Day-to-day cover

Almost all day-to-day medical expenses, e.g.general practitioner (GP) consultations andacute medication are paid from a verygenerous overall out-of-hospital benefit,with high sub-limits. GP and specialistconsultations are paid at 150% of the NIMASrate. Optometry is paid from an additionalbenefit.

Remember: All dental services,including dental expenses incurredin hospital, are paid from yourout-of-hospital benefit up tothe basic or advanced dentistrysub-limits.


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A. Day-to-day cover

BENEFITS CORE CLASSIC MILLENNIUM SUPREME

A1. Annual overall benefit Unlimited. Unlimited. Unlimited. Unlimited.

A2. Deductibles Yes (see page 14). Yes (see page 14). Yes (see page 14). None.

A3. Hospitalisation(public/private/dayclinics): Hospitalgeneral ward, ICU,medication andmaterials

Unlimited at 100% of NIMASrate*2 at designated hospitals*1

and UPFS at public facilities.







A4. Neonatal intensivecare

100% of NIMAS rate, subjectto 15 days* 2 at designatedhospitals.* 1




A5. GPs and specialists inhospital

Unlimited at 100% of NIMASrate at designated hospitals.*1




A6. Surgical proceduresfor maxillofacial andall dental services inhospital

No benefit. As per out-of-hospital basicor advanced dentistry,depending on procedure.* 2

As per out-of-hospital basic oradvanced dentistry, dependingon procedure.* 2 Deductible ofR1 700 will apply to in-hospitaladmission.

As per out-of-hospital basicor advanced dentistry,depending on procedure.* 2

A7. TTO medication No benefit. Benefit of five days peradmission from OOH benefitat designated pharmacies.* 1

Benefit of five days peradmission, subject to medicalsavings.Accumulates to threshold levelat 100% of NIMAS rate atdesignated pharmacies.* 1

Benefit of five days peradmission from OOHbenefit.* 5

A8. Blood transfusion/transport and bloodproducts

Unlimited at 100% of NIMASrate* 2 (Metropolitan HealthRisk Management’s clinicalguidelines and protocols apply).

Unlimited at 100% of NIMASrate* 2 (Metropolitan HealthRisk Management’s clinicalguidelines and protocols apply).

Unlimited at 100% of NIMASrate* 2 (Metropolitan Health RiskManagement’s clinicalguidelines and protocols apply).

Unlimited at 100% of NIMASrate* 2 (Metropolitan Health RiskManagement’s clinicalguidelines and protocols apply).

A9. Basic radiology andpathology

Unlimited at 100% of NIMASrate.* 2


Unlimited at 100% of NIMASrate.* 2&3


A10. Advanced radiology 100% of NIMAS rate,deductible of R570 perinvestigation.* 2

100% of NIMAS rate,deductible of R570 perinvestigation.* 2



A11. Radiological imaging In-hospital benefit.* 2

Member: 1 scanMember + family: 2 scansUnlimited for PMBconditions.* 2

Deductible of R850 per scan.

Joint in- and out-of-hospitalbenefit.* 2




Member: 1 scanMember + family: 2 scansUnlimited for PMB conditions.* 2

Deductible of R850 per scan.Not paid from medicalsavings.* 4




A12. Surgeon (surgicalprocedures),anaesthetist,admittingpractitioner's fees





A13. OncologyProgramme:Oncology (includingradiotherapy,chemotherapy,oncologist's fees,pathology andradiology)


100% of NIMAS rate atdesignated providers. Benefitof R113 420 per cancer patientper annum registered on theOncology Programme.






150% of NIMAS rate atdesignated providers inhospital. 100% of NIMAS rateas designated providers outof hospital. Benefit ofR283 550 per cancer patientper annum registered on theOncology Programme.

Table of benefits for 2012NIMAS rate: The NIMAS rate is based on the National Health Reference Price List (NHRPL), published in 2006 by the NationalDepartment of Health and adjusted annually, and the generic and therapeutic reference price in the case of medication.

CDL = Chronic Disease ListOOH benefit = Out-of-hospital benefitOTC = Over-the-counter medication

GP = General practitionerPMB = Prescribed Minimum BenefitICU = Intensive Care Unit

TTO = To-take-out (take home) medicationUPFS = Uniform Patient Fee Structure

Abbreviations:

A. Major medical cover

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A. Day-to-day cover


A. Major medical cover

A14. Organ transplants Unlimited at 100% of NIMASrate.* 2 Includes organand patient preparation,medication (in and out ofhospital) and hospitalisation.

Unlimited at 100% of NIMASrate.* 2 Includes organand patient preparation,medication (in and out ofhospital) and hospitalisation.



A15. Renal dialysis 100% of NIMAS rate, benefitof:* 2

Haemodialysis: R124 760 perfamily per annum.Peritoneal dialysis: R107 750per family per annum.Acute dialysis: R2 650 pertreatment.

100% of NIMAS rate, benefitof:* 2






A16. Internal/externalprosthesis

100% of cost per item, payablefrom individual prosthesisbenefit.* 2



100% of cost per item,payable from individualprosthesis benefit.* 2

A17. Medical appliances(chronic)

No benefit. Chronic appliances: 100%of cost, payable from OOHbenefit.* 2

All appliances payable fromindividual appliance list.

Chronic appliances: 100%of cost, payable from medicalsavings.* 2


Chronic appliances: 100% ofcost, payable from OOHbenefit.* 2


A18. Alcoholism, mentalconditions,pancreatic disease(non-PMB),substance abuse

100% of NIMAS rate, benefitof R11 340 per family perannum for non-PMBdiagnosis.* 2




A19. Excimer laser Excluded. Excluded. Excluded. 100% of NIMAS rate, benefitof R17 010 per family perannum.* 2

A20. HIV/AIDS Unlimited, registration on theHIV Programme required.Deductible of R230 for medicineand R1 130 for hospitalisationif not registered on HIVProgramme.Medicine must be obtained atdesignated pharmacies.* 1

Unlimited, registration on theHIV Programme required.Deductible of R230 formedicine and R1 130 forhospitalisation if notregistered on Programme.Medicine must be obtained atdesignated pharmacies.* 1

Unlimited, registration on theHIV Programme required.Deductible of R230 formedicine and R1 130 forhospitalisation if not registeredon Programme.Medicine must be obtained atat designated pharmacies.* 1

Unlimited, registration on theHIV Programme required.Deductible of R230 formedicine and R1 130 forhospitalisation if not registeredon Programme.

A21. Ambulance 100% of cost via ER24(084 124).

100% of cost via ER24(084 124).

100% of cost via ER24(084 124).

100% of cost via ER24(084 124).

B. Chronic medication

B1. Chronic medication 100% of NIMAS rate atdesignated pharmacies.* 1

Unlimited for 26 CDL PMBconditions. Reference pricingand formularies apply.

100% of NIMAS rate atdesignated pharmacies.* 1

Unlimited for 26 CDL PMBconditions. Reference pricingand formularies apply.


Unlimited for 26 CDL PMBconditions and osteoporosis,gout and gastro oesophagealreflux disease. Referencepricing and formularies apply.

100% of NIMAS rate.Unlimited for 26 CDL PMBconditions and osteoporosis,gout, benign prostatichypertrophy, psoriasis andgastro oesophageal refluxdisease. Reference pricingand formularies apply.*5

C. Day-to-day coverC1. Out-of-hospital

(OOH) benefitNo benefit. Principal member: R3 980

Adult dependant: R3 400Child dependant: R950

Payable from annual medicalsavings and above thresholdbenefit.

Principal member: R11 340Adult dependant: R8 510Child dependant: R1 190

C2. GP and specialistconsultations

No benefit unless PMB-related.

100% of NIMAS rate, payablefrom OOH benefit.

100% of cost, payable frommedical savings.Accumulates to threshold levelat 100% of NIMAS rate.


C3. Basic dentistry No benefit. 100% of NIMAS rate, payablefrom OOH benefit (includesdental expenses incurred inhospital).

Sub-limit:Member: R2 810Member + family: R5 670

100% of cost, payable frommedical savings.Accumulates to threshold levelat 100% of NIMAS rate(includes dental expensesincurred in hospital).

Sub-limit:* 3

Member: R4 450Member + 1: R6 150Member + 2: R7 310

Deductible of R1 700 will applyto in-hospital dental admission.

100% of NIMAS rate, payablefrom OOH benefit (includesdental expenses incurred inhospital).

Sub-limit:Member: R9 010Member + 1: R11 340Member + 2: R16 960


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A. Day-to-day cover


C. Day-to-day coverC4. Advanced dentistry,

dental and oralsurgery (subject topre-authorisation)

No benefit. 100% of NIMAS rate, payablefrom OOH benefit (includesdental expenses incurred inhospital).* 2


Orthodontics* 2 – one perlifetime, for beneficiariesunder the age of 18.

Dentures – one per jaw perbeneficiary every three years.

Crowns/bridges – one pertooth per beneficiary every fiveyears.

100% of cost, payable frommedical savings.* 2

Accumulates to threshold levelat 100% of NIMAS rate(includes dental expensesincurred in hospital).

Sub-limit:* 3


Orthodontics* 2 – one perlifetime, for beneficiaries underthe age of 18.



Deductible of R1 700 will applyto in-hospital dentaladmission.

100% of NIMAS rate, payablefrom OOH benefit (includesdental expenses incurred inhospital).

Sub-limit:Member: R9 010Member + 1: R11 340Member + 2: R16 960

Orthodontics* 2 – one perlifetime, for beneficiariesunder the age of 18.



C5. Acute medication No benefit. 100% of NIMAS rate atdesignated pharmacies.* 1

Payable from OOH benefit.NIMAS reference pricing apply.



Payable from medical savings.NIMAS reference pricing apply.Accumulates to threshold levelat 100% of NIMAS rate.

Sub-limit:* 3


100% of NIMAS rate, payablefrom OOH benefit.NIMAS reference pricing apply.

Sub-limit:Member: R5 620Member + 1: R9 860Member + 2: R10 180Member + 3: R10 710

C6. OTC medication(Includes OTCprescriptions forClassic andSupreme options)

No benefit. 100% of NIMAS rate atdesignated pharmacies.* 1

Payable from OOH benefit,maximum of R570 per familyper annum.


Payable from medical savings.Accumulates to threshold levelat 100% of NIMAS rate.Sub-limit* 3 of R850 per familyper annum.

Payable from OOH benefit,maximum of R1 060 perfamily per annum.

C7. Basic radiology andpathology

No benefit unless PMB-related.


100% of cost, payable frommedical savings.Accumulates to threshold levelat 100% of NIMAS rate.


C8. Advanced radiology No benefit. 100% of NIMAS rate, payablefrom OOH benefit. Deductibleof R570 per investigation.* 2

100% of NIMAS rate, payablefrom medical savings.Deductible of R570 perinvestigation.* 2

Accumulates to threshold levelat 100% of NIMAS rate.

100% of NIMAS rate, payablefrom OOH benefit.Deductible of R570 perinvestigation.* 2

C9. Radiologicalimaging (PET, MRIand CT scans)

No benefit. Joint in- and out-of-hospitalbenefit.* 2




Member: 1 scanMember + family: 2 scansUnlimited for PMB conditions.* 2

Deductible of R850 per scan.Not paid from medicalsavings.* 4




C10. OncologyProgramme:Oncology (includingradiotherapy,chemotherapy,oncologist's fees,pathology andradiology)

Joint in- and out-of-hospitalbenefit:* 2

100% of NIMAS rate atdesignated providers, benefitof R113 420 per cancer patientper annum registered on theOncology Programme.






150% of NIMAS rate atdesignated providers inhospital. 100% of NIMAS rateas designated providers outof hospital. Benefit ofR283 550 per cancer patientper annum registered on theOncology Programme.


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A. Day-to-day cover


C. Day-to-day cover

*1 Benefits will be paid to a maximum of 75% of the NIMAS rate should a non-designated hospital voluntarily be used. Should a non-designatedpharmacy be used, levies/deductibles may apply. Details of designated hospitals and pharmacies can be viewed at www.nimas.co.za or contactNIMAS on 0860 646 272.

*2 Subject to pre-authorisation.*3 Sub-limit applies across medical savings, self-payment gap and above threshold benefit.*4 Does not accumulate to threshold.*5 Medication can be obtained from Atlas, Clicks, Dis-Chem and Sparkport pharmacies. Should a non-designated pharmacy be used, levies/deductibles

may apply.Page 12

C11. Auxiliary services:Physiotherapy,homeopathy,chiropractic services,speech/occupationaltherapy, clinicalpsychology

No benefit. 100% of NIMAS rate, payablefrom OOH benefit.


100% of NIMAS rate, payablefrom medical savings.Accumulates towardsthreshold level at 100% ofNIMAS rate.

Sub-limit:* 3



Sub-limit:Member: R5 620Member + 1: R9 860Member + 2: R10 180Member + 3: R10 710

D. Additional benefits

D1. Medicalappliances/hearingaids

No benefit. Hearing aids (per family pertwo-year cycle) and post-surgery appliances: R5 670per family per annum.* 2


Hearing aids (per family pertwo-year cycle) and post-surgery appliances: R8 480 perfamily per annum.* 2&4


Hearing aids (per beneficiaryper two-year cycle): R11 340(two benefits per family).Post-surgery appliances:R11 340 per family per annum.* 2


D2. Optometry(provided viaIsoLeso optometrist)

No benefit. Service rendered by Isolesooptometrist. Benefit perbeneficiary per two-year cycle:• Vision examination• Dispensing fee• Lenses (single, bifocal or multifocal)• Contact lenses to the value of R950 (including check-up every six months) OR frames to the value of R500.

Service rendered by Isolesooptometrist. Benefit perbeneficiary per two-year cycle:• Vision examination• Dispensing fee• Lenses (single, bifocal or multifocal)• Contact lenses to the value of R1 100 (including check- up every six months) OR frames to the value of R600.

Service rendered by Isolesooptometrist. Benefit perbeneficiary per two-year cycle:• Vision examination• Dispensing fee• Lenses (single, bifocal or multifocal)• Contact lenses to the value of R1 250 (including check- up every six months) OR frames to the value of R750.

D3. Alternative tohospitalisation:(post-hospitalisationbenefit in lieu ofhospitalisation)

Home nursing, step-downfacilities, rehabilitation: fivedays per family per annum.Additional benefit may begranted subject to clinicalmotivation and pre-authorisation. Physiotherapy,occupational and speechtherapy: five days relating toadmission.* 2 Hospice: 14 daysper beneficiary per lifetime.* 2

Home nursing, step-downfacilities, rehabilitation: fivedays per family per annum.Additional benefit may begranted subject to clinicalmotivation and pre-authorisation. Physiotherapy,occupational and speechtherapy: five days relating toadmission.* 2 Hospice: 14 daysper beneficiary per lifetime.* 2

Home nursing, step-downfacilities, rehabilitation: 10 daysper family per annum.Additional benefit may begranted subject to clinicalmotivation and pre-authorisation. Physiotherapy,occupational and speechtherapy: 10 days relating toadmission.* 2 Hospice: 14 daysper beneficiary per lifetime.* 2&4

Home nursing, step-downfacilities, rehabilitation: 15 daysper family per annum.Additional benefit may begranted subject to clinicalmotivation and pre-authorisation. Physiotherapy,occupational and speechtherapy: 15 days relating toadmission.* 2 Hospice: 14 daysper beneficiary per lifetime.* 2

E. Preventative benefits

E1. Preventative benefits(subject to a definedlist of codes andclinical protocols):

Pap smears No benefit. One per female (18 - 60 years)per two-year cycle (tariff:4566).

One per female (18 - 60 years)per two-year cycle (tariff:4566).

One per female (18 - 60 years)per two-year cycle (tariff:4566).

Prostate screening No benefit. One per male (over 50 years)per two-year cycle (tariff: 4519).

One per male (over 50 years)per two-year cycle (tariff: 4519).

One per male (over 50 years)per two-year cycle (tariff:4519).

Mammogram No benefit. One per female (over 40years) per two-year cycle (tariff:34100/34300).

One per female (over 40 years)per two-year cycle (tariff:34100/34300).

One per female (over 40years) per two-year cycle(tariff: 34100/34300).

Flu vaccination One per beneficiary perannum at designatedpharmacy* 1 (NAPPI codes:836591, 813338, 825670,732826).

One per beneficiary perannum at designatedpharmacy* 1 (NAPPI codes:836591, 813338, 825670,732826).

One per beneficiary perannum at designatedpharmacy* 1 (NAPPI codes:836591, 813338, 825670,732826).

One per beneficiary perannum (NAPPI codes:836591, 813338, 825670,732826).


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Only three child dependants will be charged for. Child dependants qualify for child rates until the end of the year in which they turn 23.

CONTRIBUTIONS

CLASSIC OPTION

Principal member Adult dependant Child dependant

R1 402 R1 192 R561

MILLENNIUM OPTION

Savings contribution Risk contribution Total contribution

Principal member R450 R1 800 R2 250

Adult dependant R360 R1 440 R1 800

Child dependant R99 R396 R495

CORE OPTION


R1 040 R1 040 R416

SUPREME OPTION


R3 648 R3 369 R400

Medication

Core, Classic and Millennium optionsYou may obtain your medication fromdesignated pharmacies. If a non-designatedpharmacy is used, levies/deductibles mayapply. Details of designated pharmacies canbe viewed at www.nimas.co.za or contactNIMAS on 0860 646 272.

Supreme OptionMedication can be obtained from designatedpharmacies or all Atlas, Clicks, Dis-Chem

and Sparkport pharmacies. You mayhowever also obtain medication from apharmacy of your choice, but you will beliable for any fees charged in excess ofthe fee recommended by the Departmentof Health.

Oncology benefits

Upon registration on the OncologyManagement Programme, members will beinformed about the designated providersin their area, or visit www.nimas.co.za for a

detailed list.

Optical benefits

IsoLeso has been contracted to NIMAS toprovide optical services to its members. Forfurther details about the providers, visitwww.isoleso.co.za

P R E V E N T A T I V E B E N E F I T S

It is in your best interests to use thesebenefits to ensure that you stay healthy. Thepreventative benefits are as follows:• PAP smears

• Prostate screening• Mammogram• Flu vaccination (also available on Core Option).We will pay for these expenses as a benefit

over and above your existing benefit orsavings limits. Further details appear inthe benefit schedules on page 12 under'Preventative benefits'.

Did you know that NIMAS offers Classic, Millennium and Supreme option members a full suite ofpreventative benefits?

A designated provider is an organisation with which the Scheme has contracted to provide you and yourdependants with certain benefits. If you voluntarily choose to use a non-designated provider, a deductiblemay apply when purchasing medical goods or services.

D E S I G N A T E D P R O V I D E R S

Page 13


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D E D U C T I B L E S O N P R O C E D U R E S

A. Day-to-day cover

CORE CLASSIC MILLENNIUM

Ankle replacement No benefitunless PMBrelated. Pre-authorisationrequired.R5 720deductible willapply if non-DSP is used.

No benefit R5 720 N/A R2 860 N/A

Hiatus hernia (includingNISSEN fundoplication andother anti-reflux surgery)

R5 720 No benefit R5 720 N/A R2 860 N/A

Hip replacement No benefitunless PMBrelated. Pre-authorisationrequired.R5 720deductible willapply if non-DSP is used.


Knee replacement No benefitunless PMBrelated. Pre-authorisationrequired.R5 720deductible willapply if non-DSP is used.


Rotator cuff surgery R5 720 No benefit R5 720 N/A R2 860 N/A

Shoulder replacement No benefitunless PMBrelated. Pre-authorisationrequired.R5 720deductible willapply if non-DSP is used.


Spinal surgery R5 720 No benefit R5 720 N/A R2 860 N/A

Arthroscopy R2 860 No benefit R2 860 N/A R1 700 N/A

Conservative back treatment R2 860 No benefit R2 860 N/A R1 700 N/A

Dental admissions No benefit No benefit N/A N/A R1 700 N/A

Gynaecological laparoscopy,hysteroscopy, endometrialablation


Hernias other than hiatushernia


Laparoscopiccholecystectomy


Urinary incontinence repair R2 860 No benefit R2 860 N/A R1 700 N/A

Adenoidectomy R1 170 No benefit R1 170 N/A R1 170 N/A

Bunions R2 860 No benefit R2 860 N/A R1 170 N/A

Carpal tunnel syndrome repair R2 860 No benefit R2 860 N/A R1 170 N/A

Procedure In hospital Out of hospital In hospital Out of hospital In hospital Out of hospital

Page 14


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Durban walk-in centre Postal address

NIMAS PO Box 1000

1 Canegate Road Westville

La Lucia Ridge 3630

Umhlanga Rocks

Client Services call centre: 0860 646 272Chronic/PMBs: 0860 646 272Hospital pre-authorisation: 0860 646 272E-mail: [email protected]: www.nimas.co.zaMobisite: m.nimas.co.za

C O N T A C T D E T A I L S

A. Day-to-day cover

CORE CLASSIC MILLENNIUM

Procedure In hospital Out of hospital In hospital Out of hospital In hospital Out of hospital

Page 15

D E D U C T I B L E S O N P R O C E D U R E S ( c o n t . )

Base Multiplyis a wellnessprogrammepresenting arange of

tools to helpyou achieve

optimal health and rewards you for usingthem.

Here are just a few great tools and rewardsavailable to you:

Health Tools• Access to free health assessment and

monthly follow-ups at your nearest Clicksclinic.

• An online wellness profile providingvaluable information to assist you inliving the healthy life you deserve.

• A discounted world-class pedometer,with a network cable, that counts yoursteps, aerobic steps, calories burnt,calories in grams and your steps in

kilometres.• Access to an exercise community where

you can upload your pedometer data tohelp and support you in reaching yourfitness goals.

• Incredible discounts on annual fitnessassessments.

• Monthly newsletters packed withnutritional advice and tips to help youon your road to success.

Lifestyle Rewards• Unbelievable discounts on leading

brands, like Canon, and Garmin.• For driving enthusiasts there is a 15%

discount on Mercedes-Benz DynamicDriving courses at Zwartkop raceway.

• Great deals on high speed internet ande-mail connections with Momentumnet.

• Free annual membership to one of thelargest holiday and travel discount clubsin Southern Africa – with loads ofincredible offers, fantastic discounts ofup to 50% on your dream holiday,

including accommodation, buses, trains,coaches and so much more – allowingyou to get that break you so desperatelyneed at a fraction of the cost.

You can also upgrade to Full Multiplymembership by paying a nominal monthlyfee and increase your benefits to includemany more partners, including Virgin Active,Planet Fitness, NuMetro, Mango, Budgetcar rental and kalahari.net, to name a few.You will be contacted by a Multiply staffmember to explain the benefits in moredetail as well as how you can upgrade toFull Multiply.

Multiply's contact number is 0861 88 66 00.Please keep it at hand should you need torefer to it.

Your NIMAS membership now grants you free access to Base Multiply. Free?!? Yes,you read right, it is totally free, as long as you belong to NIMAS Medical Aid.

Colonoscopy, sigmoidoscopy R1 170 R530 R1 170 R530 R1 170 R530

Diagnostic cystoscopy R1 170 R530 R1 170 R530 R1 170 R530

Gastroscopy R1 170 R530 R1 170 R530 R1 170 R530

Hysterectomy R1 170 No benefit R1 170 N/A R1 170 N/A

Myringotomy R1 170 No benefit R1 170 N/A R1 170 N/A

Nasal endoscopy R1 170 R530 R1 170 R530 R1 170 R530

Pterygium R1 170 No benefit R1 170 N/A R1 170 N/A

Removal skin lesion R1 170 R530 R1 170 R530 R1 170 R530

Septoplasty R1 170 No benefit R1 170 N/A R1 170 N/A

Sinus washout R1 170 No benefit R1 170 N/A R1 170 N/A

Tonsillectomy R1 170 No benefit R1 170 N/A R1 170 N/A

Turbinectomy R1 170 No benefit R1 170 N/A R1 170 N/A

Tympanoplasty R1 170 No benefit R1 170 N/A R1 170 N/A

Varicose veins R2 860 No benefit R2 860 N/A R1 170 N/A

W E L L N E S S P R O G R A M M E


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