New Affiliated Provider-only procedures
From 17 October 2011 a number of high-volume procedures fall into our 'Affiliated Provider-only' category of cover. The following Q&As provide more information about these changes.
Why have you made certain procedures Affiliated Provider-only?
The changing healthcare environment and rising claims costs have a direct impact on the health insurance premiums our members pay. As a not-for-profit organisation, we try to minimise these impacts by managing increases in treatment costs. One of the ways we do this is by making certain high-volume procedures available only through our Affiliated Provider programme.
The following procedures will become Affiliated Provider-only from 17 October 2011:
- prostate surgery - aligning with those prostate-related surgeries and treatments that have previously been Affiliated Provider-only
- Mohs surgery
- intravitreal injections for age-related macular degeneration (AMD). This procedure will only be reimbursed by us if an Affiliated Provider agreement is in place, unless there is no Affiliated Provider within 100km of the member’s home.
A new Affiliated Provider-only PET/CT imaging benefit is being introduced to cover PET/CT scans. Cover is limited to cancer indications only and eligibility criteria will apply.
By making these procedures Affiliated Provider-only benefits, members can get the best value from their insurance cover and the claiming process is simplified for them.
Affiliated Provider benefits are not new for Southern Cross policies. Existing examples include colonoscopy, gastroscopy, cataract surgery, angioplasty using drug eluting stents, varicose vein surgery and private radiotherapy. We have received a lot of positive feedback from our members about the experience of using an Affiliated Provider and members continually ask us to contract with more providers.
How does the Affiliated Provider programme benefit members?
The benefit to members of having treatment from an Affiliated Provider contracted to provide a specific healthcare service include:
- certainty of cover for contracted procedures
- certainty of co-payment, if any
- an enhanced prior approval and claiming experience, as this is done by the Affiliated Provider, for contracted procedures
- no need to pay up front and claim back costs incurred
- no need to fill in claim forms and send to us
- an opportunity for Southern Cross to manage escalating claims costs and therefore keep members’ premiums as affordable as possible.
Why have you changed members’ benefits?
The benefits available to members under our policies are reviewed regularly:
- to reflect changes in the availability and costs of healthcare
- to ensure that members continue to get good value for the money they spend on their health insurance.
Can members continue to see specialists who are not Affiliated Providers?
From 17 October 2011 intravitreal injections, Mohs surgery, PET scanning and prostate surgery will only be reimbursed by us when performed by an Affiliated Provider contracted to us to do so. However we will continue to issue prior approvals for some of these procedures until we are satisfied that we have sufficient Affiliated Providers contracted. Members should contact our prior approval team on 0800 800 181 to discuss their specific circumstances.
Members can see whoever they wish for the treatment they need. However, we will only reimburse treatment provided by Affiliated Providers for intravitreal injections, Mohs surgery, PET scanning and prostate surgery from 17 October 2011.
Affiliated Provider-only benefits do not apply to members on UltraCare plans (eligibility criteria may still apply).