Posted on Jan 5, 2021 by Staff Writer
One of the key factors to consider when choosing a medical scheme is ‘affordability’. The Bestmed’s Pulse 1 premiums are determined by your personal income; hence, the monthly premiums tend to be affordable for members.
The Pulse range has two options, and both are for members who are prepared to use the scheme’s Designated Service Providers (DSPs).
Even though Bestmed’s pulse range covers you on their DSPs, the scheme also gives a comprehensive hospital cover and preventative care benefits.
Scheme benefit plan
As mentioned, Bestmed’s pulse range is a good option when you stick to their DSPs, since the scheme pays off in and out of hospital benefits from the scheme risk.
Just like most medical schemes, Bestmed has special rates on these DSPs, creating value for less at the end of the day.
Moreover, some preventative care services are paid from the scheme risk-benefit on both plans. The Pulse 2 even covers the day-to-day services from the risk-benefit.
Using the scheme’s DSPs saves you a lot of money compared using to using non-designated service providers.
In case you think the scheme only offers substandard healthcare providers, it might help you to know that included in the hospitals’ network is Netcare hospital, the largest private healthcare provider ahead of Lifecare hospitals.
All benefits relating to conditions that meet the criteria for PMBs are always covered in full when using the DSPs.
Emergency consultations done at hospitals which are not designated by Bestmed with your Family Practitioners are paid by you upfront and then later claimed back from the available out-of-network benefit.
Bestmed’s Pulse In-hospital benefits
The Bestmed’s Pulse range benefits are realised when you familiarise yourself with the Designated Service Providers (DSPs) and networks.
This way you will realise the lucrative benefits of the scheme which can make you avoid up to R11 309 in co-payments.
The DSP hospital network consists of all Netcare hospitals in South Africa. In places where there are no Netcare hospitals, Bestmed contracts other hospitals as DSPs( Designated Service Providers.
All benefits in the Pulse range are subject to pre-authorisations and clinical protocols. These are the steps followed in the hospital authorisation process:
- Make use of the Bestmed Pulse family practitioners (FPs) and should a specialist consultation be required, the FP will refer you to a Pulse Specialist DSP
- Should the Pulse specialist DSP indicate that hospitalisation is required then you need to contact Bestmed on 080 022 0106 for pre-authorisation.
In case you admitted to a non-DSP hospital due to an emergency condition, Bestmed will transfer you to a DSP nearby once you stabilise.
Below are some of the in-hospital medical events paid 100% scheme tariff from the scheme benefit in both Pulse 1 and Pulse 2:
- Hospital stay and theatre fees at a DSP hospital
- Take-home medicine limited to 3 days’ medication in Pulse 1 and 7 days in Pulse 2
- Treatment in mental health clinics is limited to 21 days per beneficiary on both plans
- Treatment of chemical and substance abuse is limited to 21 days or R30760 per beneficiary subject to network facilities in Pulse 2, while Pulse 1 only covers PMBs conditions.
- Consultations and procedures
- Surgical procedures and anaesthetics. Pulse 1 excludes conditions like Epilepsy, Parkinson’s disease and procedures where stimulators are used.
- Only PMBs fitting conditions for organ transplants are covered in both plans
- Pulse 2 covers major medical maxillo-facial surgery strictly related to certain conditions while Pulse 1 does not provide for these benefits
- Dental and oral surgery covered in Pulse 2 only
Bestmed’s Pulse Out of hospital benefits
In Pulse 1, primary care services and the Scheme benefits are subjected to treatment protocols, preferred providers, DSPs, dental procedure codes, pathology and radiology lists of codes and medicine formularies as accepted by the Scheme.
Pulse 1 members get as many consultations as necessary. Benefits also cover a selected minor trauma treatment such as stitching of wounds. Medicine for acute ailments is also covered, however, it is subject to the Bestmed Pulse1 formulary.
In Pulse 2, out-of-hospital benefits are paid at 100% Scheme tariff. All Pulse 2 members should use Bestmed Pulse Specialist DSPs.
To get the list of service providers, members can find them on the company’s website www.bestmed.co.za or call in to get information on the Pulse Specialist DSP closest to you.
Below are some of the medical events with their respective scheme benefits:
- In Pulse 2 the overall day-to-day limit is R13 854 for members and R27 537 when the family is included. Pulse one does not have a day-to-day option.
- There are unlimited FP( Family Practitioner) consultations, subject to respective FP network providers as stated in the plan.
- Diabetes primary care consultation is paid 100% at Scheme tariff subject to registration with HaloCare. There are 2 primary care consultations at Dis-Chem Pharmacies limited to R341.90 per consultation. In Pulse 2, the benefit is paid first from the day-to-day benefit
- Basic radiology and pathology are subjected to any of the options’ respective protocols as listed in the plan
- Pulse 1 has no benefits for specialised diagnostic imaging. While in Pulse 2, benefits are subject to pre-authorisation and a maximum of 3 scans per beneficiary.
- In Pulse 1, HIV / AIDS is covered on conditions fitting PMBs, only at DSPs. While Pulse 2 covers these at 100% Scheme tariff, subject to pre-authorisation and DSPs.
- Peritoneal dialysis and haemodialysis are only covered on DSPs in both Pulse 1 and Pulse 2 at 100% scheme tariff. Pulse 1 covers conditions that fit in the PMBs category.
- Oncology programme is at 100% Scheme tariff; however, Pulse 1 only covers PMB fitting condition at DSPs.
Bestmed’s Pulse Medicine
Medicine benefits in both Bestmed’s Pulse options may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP).
Approved CDL, PMB and non-CDL chronic medicine costs are paid from the non-CDL chronic medicine limit first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
Approved PMB biological and Non-PMB biological medicine costs are paid from the Biological limit first. Once the limit is depleted, only PMB biological medicine costs will continue to be paid unlimited from Scheme risk.
Below are some of the medicine benefits:
- CDL & PMB chronic medicine is at 100% Scheme tariff on both options. In Pulse 1 there is 40% co-payment on non-formulary medicine, and 25% in Pulse 2.
- Pulse 1 has no benefits to cover non-CDL chronic medicine. While Pulse 2 covers 16 conditions at 90% Scheme tariff. Principal members are limited to R6 559 and R13 118 limit when a family is included. There are co-payment of 20% for non-formulary medicine.
- Biologicals and other high-cost medicine are limited to R149 279 per beneficiary in Pulse 2. While Pulse 1 covers PMBs only and is subject to pre-approval.
- Acute medicine is at 100% Scheme tariff on both options. Pulse 1 is subject to Bestmed formulary while Pulse 2 members are limited to R4 354 and R8 821with family-inclusive (subject to day-to-day limit).
- Over the counter medicine is limited to R368 per family in Pulse 1 and R579 per family in Pulse 2.
Preventative care benefits
Bestmed’s Pulse preventative benefits may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP).
Below are covered Preventative benefits:
- Flu vaccines
- Pneumonia vaccines
- Female contraceptives are limited to R2 205 per beneficiary per year
- Back and neck preventative programme
- Paediatric immunisations
- HPV vaccinations for Females from 9-26 years
- The famous Bestmed’s Tempo wellness programme for adults aged 18 and above
- Maternity benefits
The Pulse range contributions are determined by your income level. There are 3 categories of contributions in each option.
Below is the total contributions for all Pulse 1 income levels.
Total contribution for income from R0 – R5 500 is:
Principal member – R1 626
Adult dependant – R1 545
Child dependant- R978
Total contribution for income from R5 501 to R8 500 is:
Principal member – R1 953
Adult dependant – R1 856
Child dependant – R1 172
Total contribution for income above R8 500 is:
Principal member – R2 344
Adult dependant – R2 109
Child dependant – R1 172
Contributions for Pulse 2 members 2020
Principal member – R5 770
Adult dependant – R5 770
Child dependant – R1 371
You can only add up to 4 child beneficiaries in your Pulse 2 medical plan and the rest will be added as beneficiaries for free.
Competitive advantages of Bestmed’s Pulse range
- The Pulse category is open to qualifying members from all income groups
- Use of DSPs lowers your monthly premiums while giving you value for money by choosing the best service providers in the country
- A plan can contribute to a maximum of 4 child dependants and the rest are included for free, this should be a cause to join for members with big families
- There are few co-payments in both Pulse options
- The Bestmed’s Tempo wellness programme is free for all members and strives to keep your health on check
Competitive disadvantages of the Pulse range
- Bestmed’s Pulse range is limiting members’ hospital choice because of their emphasis on using the scheme’s listed service providers, sometimes subject to pre-authorisation.
- There is no provision for a savings account in both plans, meaning, even if you did not use your medical aid you will still have to subscribe the same amount in the following year. No account credit can be carried to next year.
Bestmed is associated with reputable service providers such that, even if members’ choices are limited, the available options still offer value. Along with other leading medical schemes such as Bonitas, it provides value for money medical schemes.
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