- Previous Option 2 Option Z - Previous Option D - Previous Option 3 Benefit options Current benefit structures A detailed description of the benefit options (benefit structure) before the amalgamation, in respect of the individual schemes which will be amalgamated, should be submitted. Please note that the table below merely serves as an example and should be adjusted to be relevant to the schemes to be amalgamated: Scheme A Scheme B Option A Option B Option C Option D Option 1 Option 2 Option 3 Type Traditional – Fee for service New generation – negotiated fee for service New generation – fee for service Capitated – low cost option Traditional – Fee for service New generation – negotiated fee for service Capitated – low cost option In-hospital benefits (overall limits & rate) PMB Unlimited Rate: 300% of scheme rate Unlimited Rate: 150% of scheme rate Unlimited R1m limited per family per annum Rate: 100% of scheme rate Unlimited R500 000 per family per annum Rate: 100% of scheme rate Unlimited Rate: 300% of scheme rate Unlimited Rate: 150% of scheme rate Unlimited R750 000 per family per annum Rate: 100% of scheme rate Out-hospital benefits (overall limits & rate) PMB Unlimited Limited to 200% of scheme rate Unlimited Limited to 150% of scheme rate Unlimited From savings only Unlimited Unlimited capitated Unlimited Limited to 200% of scheme rate Unlimited Limited to 150% of scheme rate Unlimited Unlimited capitated Chronic conditions PMB - Non-PMB PMB + R50 000 per family per annum Formulary PMB + R20 000 per family per annum Formulary PMB Formulary PMB PMB + R50 000 per family per annum Formulary PMB + R20 000 per family per annum Formulary PMB – capitated Contributions pmpm pbpm R3 000 R2 000 R2 200 R1 100 R1 100 R650 R500 R250 R2 500 R1 300 R1 800 R900 R1 000 R450 Income bands per < R 1000 R 1 000 – R3 000 No income bands No income bands No income bands < R1000 R1 000 000 No income bands No income bands
current membership R3 001 – R5 000 > R5 000 R3 001 000 >R5 000 Personal Medical Savings Accounts (PMSA) No PMSA 15% of total contributions 20% of total contributions No PMSA No PMSA 15% of total contributions 25% of total contributions Average family size 3.4 2.7 2.1 2.6 2.6 2.3 2.1 Average age 34.8 years 32.5 years 28.0 years 29.3 years 31.8 years 29.3 years 28.1 years Ave. pensioner ratio (65+ yrs) 7.4% 3.2% 2.2% 1.9% 8.4% 2.7% 3.4% Benefit design of amalgamated scheme A detailed description of the benefit options (benefit structure) of the amalgamated scheme should be provided. For example: Option X Option Y Option Z No overall hospital limit 200% of scheme rate sub limits applicable No overall hospital limit 150% of scheme rate sub limits applicable R750 000 overall hospital limit per family 100% scheme rate within a network hospitals R750 deductible is payable for certain procedures. No Threshold Threshold: B = R5 300 F = R8 000 No Threshold Chronic conditions: PMB + R50 000 per family per annum Chronic conditions: Formulary PMB + R20 000 per family per annum. Chronic conditions: Formulary PMB – capitated Personal medical savings account: N/A Personal medical savings account: 15% of GC Personal medical savings account: 25% of GC General practitioners - Unlimited General practitioners – Limited to 20 visits per beneficiary General practitioners – limited to network of doctors