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Health Plans | Access

Benefits Access Option 2019

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

Overall Annual Limit

Unlimited hospitalisation In Network
Subject to sub-limits not being exceeded

Annual Member Savings Account:
Member = R 5 484
Adult = R 4 716
Child = R 1 068
Out of hospital subject to sub limits and MSA*

Unlimited hospitalisation In Network
Subject to sub-limits not being exceeded

Annual Member Savings Account:
Member = R 5 654
Adult = R 4 870
Child = R 1 099
Out of hospital subject to sub limits and MSA*

Rand sub limit increased by 3.1%
Rand sub limit increased by 3.3%
Rand sub limit increased by 2.9%

Prorated benefits are applicable if you join after the 1st of January of a benefit year.

Yes Yes  

Statutory prescribed minimum benefits.  Services rendered payable at 100% of cost at DSP*

No Annual Limit No Annual Limit  

3 Month General Waiting Periods (Subject to the rights of interchangeability)

Yes Yes  

12 Months condition specific waiting period for pre-existing conditions (Subject to the rights of interchangeability)

Yes Yes  

Claims received later than the last day of the 4th month in which the service was rendered will not be covered.

Yes Yes  
Emergency medical cover whilst traveling outside of South Africa. (Subject to PMBs)

100% of Scheme rates payable in RSA currency.

Subject to completion of documentation prior to leaving RSA.
Subject to approval by Scheme

100% of Scheme rates payable in RSA currency.

Subject to completion of documentation prior to leaving RSA.
Subject to approval by Scheme


 

 

Benefits (In hospital)

HOSPITALISATION AND ASSOCIATED COSTS – PROVINCIAL AND PRIVATE

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

Items 1.01 – 1.25
Limited collectively and subject to authorisation.

Note:  All Admissions to hospitals and services listed below must be pre-authorised by the Scheme/preferred provider or within 48 hours in the case of an emergency. 

Failure to comply with this rule will result in a levy of R 1 000 per admission.  Please note that treatment protocols apply.


Private and State Hospitals
Unlimited benefits for PMB conditions subject to pre-authorisation and use of a Designated Service Provider (DSP*) hospital network and prevailing public hospital protocols

Subject to 100% of DSP Tariff* and clinical protocols

Failure to comply utilising a DSP* provider will result in a 10% co-payment* per admission except for emergency admissions

Private and State Hospitals
Unlimited benefits for PMB conditions subject to pre-authorisation and use of a Designated Service Provider (DSP*) hospital network and prevailing public hospital protocols

Subject to 100% of DSP Tariff* and clinical protocols

Failure to comply utilising a DSP* provider will result in a 10% co-payment* per admission except for emergency admissions.

 

1.01 Accommodation, Theatre Fees, Medicines, Intensive Care
Subject to Pre-authorisation and PMB’s

100% of DSP Tariff*
TTO benefit for 5 days.
Subject to formulary*

100% of DSP Tariff*
TTO benefit for 5 days.
Subject to formulary*

 

1.02 Surgical Procedures including GP and Specialist Consultations.

Subject to Pre-authorisation and PMB’s


100% of Scheme Tariff*

100% of Scheme Tariff*

 

1.03 Diagnostic Investigations
E.g. Radiology, Pathology, MRI/PET/CAT scans etc.
Subject to Clinical protocols and PMB’s. 

Authorisation must be obtained prior to the examination or within 24 hours in case of emergency.
All specialised radiology subject to pre-authorisation.

100% of Scheme Tariff*
Subject to Clinical protocols and PMB’s

 

Pathology unlimited

Radiology unlimited

Specialised Radiology:
MRI/PET/CAT Scans Limited to 2 per beneficiary per annum for In and Out Hospital

100% of Scheme Tariff*
Subject to Clinical protocols and PMB’s

 

Pathology unlimited

Radiology unlimited

Specialised Radiology:
MRI/PET/CAT Scans Limited to 2 per beneficiary per annum for In and Out Hospital

 

1.04 Blood Transfusions

100% of Scheme Tariff*
Subject to PMB conditions only

100% of Scheme Tariff*
Subject to PMB conditions only

 

1.05 Oncology
Subject to PMB’s as prescribed.  Treatment subject to designated service provider guidelines and pre-authorisation.

100% of DSP Tariff*
Limited to PMB conditions only and subject to DSP* ICON* Standard protocols

100% of DSP Tariff*
Limited to PMB conditions only and subject to DSP* ICON* Standard protocols

 

1.06 Psychiatric Treatment including Clinical Psychology
Subject to PMB’s, managed care protocols and pre-authorisation by the Scheme.

All treatment in hospital, including accommodation, medicines, materials, procedures, consultations, and psychiatry/psychology therapy sessions.

100% of Scheme Tariff*
Subject to PMB conditions

Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum

100% of Scheme Tariff*
Subject to PMB conditions

Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum

 

1.07 Drug & Alcohol Rehabilitation

Subject to PMB’s, Managed care protocols and pre-authorisation


100% of Scheme Tariff*

Limited to R 11 183 per family per annum
PMB based on clinical protocols

100% of Scheme Tariff*

Limited to R 11 765 per family per annum
PMB based on clinical protocols

Rand sub limit increased by 5.2%

1.08 Organ Transplants

Subject to PMB’s and pre-authorisation


100% Scheme Tariff*
PMB based on Department of Health Protocols, Unlimited

100% Scheme Tariff*
PMB based on Department of Health Protocols, Unlimited

 


1.09 Dental Hospitalisation
Subject to pre-authorisation, and treatment protocols and PMB’s

100% of Scheme Tariff*
Subject to PMB conditions only

Subject to pre-authorisation

 

100% of Scheme Tariff*
Subject to PMB conditions only

Subject to pre-authorisation

 

1.10 Renal Dialysis

Subject to PMB’s and to pre-authorisation

100% of Negotiated Tariff*
Unlimited benefits for PMB admissions and PMB level of Care.

Subject to Treatment Protocols and formulary*.

100% of Negotiated Tariff*
Unlimited benefits for PMB admissions and PMB level of Care.

Subject to Treatment Protocols and formulary*.

 

1.11 Sterilisation/Vasectomy

Subject to pre-authorisation


100% of Scheme Tariff*
Subject to PMB conditions only

100% of Scheme Tariff*
Subject to PMB conditions only

 


1.12 Internal and External Prosthesis
Subject to PMB’s, pre-authorisation and protocols.

 

Back surgery/Spinal procedures instrumentation and disc prostheses including all components and fixation devices
Subject to confirmation that beneficiary has completed a course of conservative back treatment.

 

 

 

Joint replacement: Limited to one event per annum unless sepsis or trauma
(Hip, Knee, Shoulder and Ankle)

 

Aphakic Lenses (Subject to protocol and PMB’s)

 

Cardiac stents

 

Cardiac Valves, Aortic stent grafts, peripheral arterial stents grafts, Single/dual pacemaker

Cardiac resynchronization devices (CRT), Implantable Cardioverter Defibrillators (ICD) with Pacing Capabilities (CRT-D)

 

 

Internal sphincters and stimulators

Neurostimulators/Internal nerve stimulator for Parkinson’s Disease

 

Cochlear implants

Insulin pumps and monthly materials

 

Unlisted prosthesis
Artificial Limbs and external prostheses including artificial eyes

 

 

 

Cardiac Valves, Aortic stent grafts, peripheral aterial stents grafts, Single/dual pacemaker

Cardiac resynchronization devices (CRT), Implantable Cardioverter Defibrillators (ICD) with Pacing Capabilities (CRT-D)

 

Internal sphincters and stimulators

 

Neurostimulators/Internal nerve stimulator for Parkinson’s Disease

 

Cochlear implants

 

Insulin pumps and monthly materials

 

Unlisted prosthesis

 

Artificial Limbs and external prostheses including artificial eyes

100% of Negotiated Tariff*
Limited to R 27 958 per family per Annum
Subject to PMB only

Sub Limits:
Subject to PMB only

 

 

Subject to overall limit and one procedure per beneficiary per annum unless PMB

 

R 4 473 per lens

Subject to PMB only. Maximum of 3 stents as per public hospital protocols for STEMI. No benefit for unstable angina or NSTEMI unless there is evidence of failed conservative medical treatment.

Subject to overall prosthesis limit and PMB protocols

Subject to prevailing public hospital protocols and PMB for secondary prevention only.
Overall Limit applies for primary prevention.

 

 

No benefit – subject to PMB

No Benefit

No Benefit

Maximum R 10 550 subject to overall prosthesis limit

Subject to overall limits

PMB – UPFS rates applicable

 

100% of Negotiated Tariff*
Limited to R 29 412 per family per Annum
Subject to PMB only

Sub Limits:
Subject to PMB only

 

 

Subject to overall limit and one procedure per beneficiary per annum unless PMB

 

R 4 706 per lens

Subject to PMB only. Maximum of 3 stents as per public hospital protocols for STEMI. No benefit for unstable angina or NSTEMI unless there is evidence of failed conservative medical treatment.

Subject to overall prosthesis limit and PMB protocols

Implantable Cardioverter Defibrillator (ICD); Subject to Scheme protocol and PMB for primary and secondary prevention
Cardiac Resynchronization Therapy (CRT) with Pacing Capabilities (CRT-D); Subject to Scheme protocol and PMB

No benefit – subject to PMB

No Benefit

No Benefit

Maximum R 11 099 subject to overall prosthesis limit

Subject to overall limits

PMB – UPFS rates applicable

Rand sub limit increased by 5.2%

 

 

 

 

 

 

Rand sub limit increased by 5.2%

 

 

 

 

 

Introduction of Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy (CRT) with Pacing Capabilities (CRT-D)

 

 

 

Rand sub limit increased by 5.2%

 

 

1.13 Physiotherapy & Biokinetics
Subject to PMB’s, treating doctor referral and pre-authorisation by the auxiliary service provider during the admission period
Subject to Scheme protocols

100% of Scheme Tariff*
Subject to PMB conditions only

100% of Scheme Tariff*
Subject to PMB conditions only

 

1.14 Dietician & Occupational Therapy
Subject to PMB’s, treating doctor referral and pre-authorisation by the auxiliary service provider during the admission period

Subject to Scheme protocols

100% of Scheme Tariff*
Subject to PMB conditions only

100% of Scheme Tariff*
Subject to PMB conditions only

 


1.15 Step Down Facilities
In lieu of hospitalisation
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*

Limited to 14 days per beneficiary per annum

100% of Negotiated Tariff*

Limited to 14 days per beneficiary per annum

 

1.16 Private Nursing
In lieu of hospitalisation
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*
Subject to PMB conditions only
Limited to 14 days per beneficiary per annum

100% of Negotiated Tariff*
Subject to PMB conditions only
Limited to 14 days per beneficiary per annum

 

1.17 Rehabilitation Facilities
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff

Limited to 14 days per beneficiary per annum

100% of Negotiated Tariff

Limited to 14 days per beneficiary per annum

 

1.18 Circumcision
Subject to pre-authorisation

100% of Scheme Tariff* at GP or 100% of Scheme Tariff* at Specialist

Out of Hospital Only

100% of Scheme Tariff* at GP or 100% of Scheme Tariff* at Specialist

Out of Hospital Only

 

1.19 Hyperbaric Oxygen Therapy
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*
Subject to PMB conditions only

100% of Negotiated Tariff*
Subject to PMB conditions only

 

1.20 Negative pressure wound therapy
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*
Subject to PMB conditions only

100% of Negotiated Tariff*
Subject to PMB conditions only

 

1.21 Medication for Age Related Macular Degeneration
Subject to PMB’s, pre-authorisation and Scheme formulary* and protocol

Subject to PMB conditions only

Subject to PMB conditions only

Limited to R 666 per fill and 4 fills per eye per annum

Introduction of sub-limits and limitation on number of fills

1.22 Back Surgery
Subject to PMB’s, pre-authorisation and protocols.

Limited to PMB conditions as per prevailing public hospital protocols and regulations. Excludes disc prostheses and spinal cages. Second opinion required for non-trauma related surgery.

Back Surgery for the above procedures will only be funded subject to adherence of the conservative back treatment protocol.

.

Limited to PMB conditions as per prevailing public hospital protocols and regulations. Excludes disc prostheses and spinal cages. Second opinion required for non-trauma related surgery.

Back Surgery for the above procedures will only be funded subject to adherence of the conservative back treatment protocol.

 

1.23 Stereotactic Radio-Surgery
Subject to PMB’s, pre-authorisation and protocols.
Only Covered for Primary Central Nervous System Tumours

100% of Scheme Tariff*
Laparoscopic Hospitalisation & Associated costs will attract a R 5 592 co-payment*

100% of Scheme Tariff*
Laparoscopic Hospitalisation & Associated costs will attract a R 5 592 co-payment*

 

1.24 Laparoscopic Hospitalisation and Associated Costs
Subject to PMB’s, pre-authorisation and protocols.
Performed in a Day Hospital or as a day case

  • Skin disorders
  • Arthroscopy
  • Bunionectomy
  • Removal of varicose veins
  • Refractive eye surgery, Aphakic lenses
  • Infertility treatment
  • Non-cancerous breast conditions

 

  • Skin disorders
  • Arthroscopy
  • Bunionectomy
  • Removal of varicose veins
  • Refractive eye surgery, Aphakic lenses
  • Infertility treatment
  • Non-cancerous breast conditions

 

 

1.25 Exclusions for Hospital Admissions & Treatment Related to:

(In conjunction with the Overall Scheme Exclusion List and subject to PMB’s)

R 1 583
Deductible* – Except for PMB’s

  1. Tonsillectomy and adenoidectomy
  2. Colonoscopy
  3. Facet joint injections

Myringotomy

R 3 165
Deductible* – Except for PMB’s

  1. Gastroscopy
  2. Cystoscopy
  3. Hysteroscopy
  4. Flexible sigmoidoscopy
  5. Percutaneous radiofrequency ablations

Percutaneous rhizotomies

R 5 275
Deductible* – Except for PMB’s

  1. Elective caesarean delivery
  2. Joint replacements
  3. Back surgery, including spinal fusion
  4. Umbilical hernia repair
  5. Hysterectomy
  6. Functional nasal surgery

R 1 583
Deductible* – Except for PMB’s

  1. Tonsillectomy and adenoidectomy
  2. Colonoscopy
  3. Facet joint injections

Myringotomy

R 3 165
Deductible* – Except for PMB’s

  1. Gastroscopy
  2. Cystoscopy
  3. Hysteroscopy
  4. Flexible sigmoidoscopy
  5. Percutaneous radiofrequency ablations

Percutaneous rhizotomies

R 5 275
Deductible* – Except for PMB’s

  1. Elective caesarean delivery
  2. Joint replacements
  3. Back surgery, including spinal fusion
  4. Umbilical hernia repair
  5. Hysterectomy
  6. Functional nasal surgery

 

DAY HOSPITAL PROCEDURES

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

Day Hospital Procedures
Procedures to be done at Designated Service Provider (DSP*) hospital network
Subject to pre-authorisation

Subject to Scheme Tariff*
Co-Payment* applicable to defined conditions above
Subject to PMB conditions only:

  1. Tonsillectomy and adenoidectomy
  2. Umbilical and Inguinal hernia repair
  3. Colonoscopy
  4. Cystoscopy
  5. Gastroscopy and Oesophagoscopy
  6. Hysteroscopy
  7. Myringotomy
  8. Grommets
  9. Termination of pregnancy
  10. Breast biopsy
  11. Cataracts
  12. Circumcision
  13. ERCP
  14. Haemorrhoidectomy
  15. Vasectomy
  16. Tubal Ligation
  17. Excision of extensive skin lesions or repair of wounds and skin grafts
  18. Dental procedures
  19. Repair nail bed & Removal of toenails
  20. Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger finger, ganglion, carpal tunnel syndrome
Minor Gynaecological procedures – cone biopsy, colposcopy, D&C

Subject to Scheme Tariff*
Co-Payment* applicable to defined conditions above
Subject to PMB conditions only:

  1. Tonsillectomy and adenoidectomy
  2. Umbilical and Inguinal hernia repair
  3. Colonoscopy
  4. Cystoscopy
  5. Gastroscopy and Oesophagoscopy
  6. Hysteroscopy
  7. Myringotomy
  8. Grommets
  9. Termination of pregnancy
  10. Breast biopsy
  11. Cataracts
  12. Circumcision
  13. ERCP
  14. Haemorrhoidectomy
  15. Vasectomy
  16. Tubal Ligation
  17. Excision of extensive skin lesions or repair of wounds and skin grafts
  18. Dental procedures
  19. Repair nail bed & Removal of toenails
  20. Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger finger, ganglion, carpal tunnel syndrome
Minor Gynaecological procedures – cone biopsy, colposcopy, D&C
 

Benefits (Out of hospital)

GENERAL PRACTITIONERS AND SPECIALIST

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

2.1 Consultations (Out-of-Hospital – Including General Practitioners, Specialist and Outpatient Facilities)

100% Scheme Tariff*

General Practitioner Consultations:
Paid from MSA*
6 Additional GP Visits per Family once MSA* depleted

 

Specialist Consultations:
Paid from MSA*

 

Specialist consultations requires GP referral or payment will be made at GP rates

100% Scheme Tariff*

General Practitioner Consultations:
Paid from MSA*
6 Additional GP Visits per Family once MSA* depleted

 

Specialist Consultations:
Paid from MSA*

 

Specialist consultations requires GP referral or payment will be made at GP rates

 

2.2 Diagnostic Investigations
Subject to PMB’s and protocols.

All specialised radiology subject to pre-authorisation.

100% of DSP Tariff*
Paid from MSA*
Radiology and Pathology:
Subject to PMB’s

Specialised Radiology:
MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum. In & Out of Hospital as per 1.03 above.
Subject to pre-authorisation.

100% of DSP Tariff*
Paid from MSA*
Radiology and Pathology:
Subject to PMB’s

Specialised Radiology:
MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum. In & Out of Hospital as per 1.03 above.
Subject to pre-authorisation.

 

MEDICINES & INJECTION MATERIAL

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

3.1 Acute Medicines


 

100% of Reference Price*
Paid from MSA*
Subject to Medicine formulary* and Protocols, Including Materials.

 

Homeopathic Medication excluded

Acute Medication Obtained from Pharmacy:
R 1 794 per beneficiary limited to
R 4 431 per family per annum

100% of Reference Price*
Paid from MSA*
Subject to Medicine formulary* and Protocols, Including Materials.

 

Homeopathic Medication excluded

Acute Medication Obtained from Pharmacy:
R 1 887 per beneficiary limited to
R 4 661 per family per annum

Rand sub limit increased by 5.2%
Rand sub limit increased by 5.2%

3.2 PMB Chronic Disease List Medicines
PMB’s subject to registration and pre-authorisation with the Schemes preferred provider.
Chronic Medication to be Obtained from Preferred Provider Network.

Subject to renewal of prescription every six months.

100% of Reference Price*
Unlimited
Paid from Risk Pool

Subject to pre-authorisaion, Treatment Protocols, Medicine formulary* and Registration of the Chronic Medicine by GP.


100% of Reference Price*
Unlimited
Paid from Risk Pool

Subject to pre-authorisaion, Treatment Protocols, Medicine formulary* and Registration of the Chronic Medicine by GP.



3.3 Other Chronic (Non CDL) Medicines
PMB’s subject to registration and pre-authorisation with the Schemes preferred provider.
Chronic Medication to be Obtained from Preferred Provider Network.

Subject to renewal of prescription every six months.


100% of Reference Price
Paid from MSA*
Maximum R 90 per Script.
Subject to Benefit for Medication in 3.1 above.
Subject to formulary*
Cost at Single Exit Price and Regulated Dispensing Fee.
PAT Not chargeable with Acute Script on the Same Day.
Network Provider Only

100% of Reference Price
Paid from MSA*
Maximum R 95 per Script.
Subject to Benefit for Medication in 3.1 above.
Subject to formulary*
Cost at Single Exit Price and Regulated Dispensing Fee.
PAT Not chargeable with Acute Script on the Same Day.
Network Provider Only

Rand sub limit increased by 5%

Wording amended


3.4 Pharmacy Advised Treatment (PAT)
Over the Counter Medication
Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines.

PAT subject to acute benefit limit

100% of Reference Price
Paid from MSA*
Limited to R 74 per beneficiary per month, subject to R 886 per family per annum. Subject to oral and injectable contraceptives only
Subject to the contraceptive formulary*


100% of Reference Price
Paid from MSA*
Limited to R 78 per beneficiary per month, subject to R 932 per family per annum. Subject to oral and injectable contraceptives only
Subject to the contraceptive formulary*

Rand sub limit increased by 5.2%
Rand sub limit increased by 5.2%

OPTICAL BENEFIT
Contact the Schemes Preferred Provider Network for availability and Locality of Network Optometrists

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

4.1 Spectacle Lenses:  In Network
Benefit applicable to members who utilize the Scheme’s Preferred Provider Network Optometrists only

Limited to one pair of spectacles per beneficiary every 24 months


 

100% of DSP Tariff*
Paid from Risk Pool
R 175 per lens – clear single vision
or
R 380 per lens – clear bifocal 
or
R 380 per lens – base multifocal
No Benefit for Fixed Tints
No benefit for contact lenses if spectacles purchased

100% of DSP Tariff*
Paid from Risk Pool
R 175 per lens – clear single vision
or
R 410 per lens – clear bifocal 
or
R 410 per lens – base multifocal
No Benefit for Fixed Tints
No benefit for contact lenses if spectacles purchased

Rand sub limit increased by 7.89%

Rand sub limit increased by 7.89%

4.2 Contact Lenses:  In Network
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only

One claim per beneficiary every 24 months

Subject to optical protocol


100% of DSP Tariff*
Paid from Risk Pool
R 840 per beneficiary every 24 months. 
No claim for spectacles if contact lenses purchased.

100% of DSP Tariff*
Paid from Risk Pool
R 900 per beneficiary every 24 months. 
No claim for spectacles if contact lenses purchased.

Wording amended
Rand sub limit increased by 7.14%

4.3 Frames/Lens Enhancements:  In Network
A frame cannot be claimed alone or with contact lenses.
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only

One claim per beneficiary every 24 months

100% of DSP Tariff*
Paid from Risk Pool

R 315 per Frame

100% of DSP Tariff*
Paid from Risk Pool

R 548 per Frame

Wording amended

Rand sub limit increased by 73.97%

4.4 Eye Tests:  In Network
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only One claim per beneficiary every 24 months



100% of DSP Tariff*
Paid from Risk Pool
One comprehensive consultation per beneficiary every 24 months

100% of DSP Tariff*
Paid from Risk Pool
One comprehensive consultation per beneficiary every 24 months

Wording amended

DENTISTRY BENEFIT

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

5.1 Conservative Dentistry (Dentist and Dental therapist)


 

100% of Scheme Tariff*
Paid from Risk Pool
Consultations, Fillings, Extractions
Preventative scale and polish
Fluoride treatment limited to beneficiaries below the age of 12 years

X-rays (limited to intra-oral)

Dental protocols apply and pre-authorisation required for extensive treatment plans
Quantity Limitations Apply
Contracted Network Provider Only

100% of Scheme Tariff*
Paid from Risk Pool
Consultations, Fillings, Extractions
Preventative scale and polish
Fluoride treatment limited to beneficiaries below the age of 12 years

X-rays (limited to intra-oral)

Dental protocols apply and pre-authorisation required for extensive treatment plans
Quantity Limitations Apply
Contracted Network Provider Only

 

 

5.2 Advanced Dentistry

Subject to pre-authorisation by the Scheme and treatment protocols. 

Failure to obtain pre-authorisation will result in no payment.


Non-PMB’s Paid from MSA*
Acrylic (Plastic) Dentures
1 set of Acrylic/plastic dentures per beneficiary every 4 years. Cover available for realigning and repairing every 12 months
Including Repairs of Dentures

 

Subject to PMB conditions only

Non-PMB’s Paid from MSA*
Acrylic (Plastic) Dentures
All clinically valid specialised dental treatment covered from MSA* including 1 set of Acrylic (plastic) denture per beneficiary every 4 years.
Cover available for realigning and repairing every 12 months
Including Repairs of Dentures

Subject to PMB conditions only

Wording amended

5.3 Maxillo-Facial & Oral, including Dental Surgery
(Consultations, Surgical procedures and Operations) Subject to PMB’s, pre-authorisation and protocols.

Subject to PMB conditions only

Paid from Risk Pool

Subject to PMB conditions only

Paid from Risk Pool

 

AUXILIARY BENEFIT

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

6.1 ALTERNATIVE SERVICES
Homeopathy, Naturopathy, Chiropractor and Podiatry

100% of Scheme Tariff*
Non-PMB’s paid from MSA*
Appropriate referral by GP/Specialist, failing to do so will result in no payment. 
Subject to PMB’s and Protocols
Medicine dispensed limited to Acute Medication Limit (3.1).
Homeopathic Medication Excluded

100% of Scheme Tariff*
Non-PMB’s paid from MSA*
Appropriate referral by GP/Specialist, failing to do so will result in no payment. 
Subject to PMB’s and Protocols
Medicine dispensed limited to Acute Medication Limit (3.1).
Homeopathic Medication Excluded

 

 

6.2 REMEDIAL AND OTHER THERAPIES
Audiology, Speech therapy, Dieticians, Hearing Aid Acousticians, Occupational Therapy, Orthotics, Social Workers and Speech Therapy

100% of Scheme Tariff*
Subject to PMB conditions and clinical protocols
Non-PMB’s paid from MSA*
Appropriate referral by GP/Specialist, failing to do so will result in no payment. 

Subject to PMB’s

100% of Scheme Tariff*
Subject to PMB conditions and clinical protocols
Non-PMB’s paid from MSA*
Appropriate referral by GP/Specialist, failing to do so will result in no payment. 

Subject to PMB’s

 

6.3 PHYSIOTHERAPY OUT OF HOSPITAL Biokinetics & Physiotherapy

100% of Scheme Tariff*
Subject to PMB conditions and clinical protocols
Non-PMB’s paid from MSA*
Cardiac and Respiratory conditions:
Subject to provision of treatment plan and therapy goals. Maximum of 6 sessions per beneficiary, thereafter subject to progress report and evidence of response.
Treatment for Back pain:

Subject to treatment plan required detailing therapy goals and education programme to transfer self-management skills. Maximum of 3 sessions per week for 3 weeks. Thereafter, subject to progress reports and evidence of goals achieved.

100% of Scheme Tariff*
Subject to PMB conditions and clinical protocols
Non-PMB’s paid from MSA*
Cardiac and Respiratory conditions:
Subject to provision of treatment plan and therapy goals. Maximum of 6 sessions per beneficiary, thereafter subject to progress report and evidence of response.
Treatment for Back pain:

Subject to treatment plan required detailing therapy goals and education programme to transfer self-management skills. Maximum of 3 sessions per week for 3 weeks. Thereafter, subject to progress reports and evidence of goals achieved.

 

APPLIANCES

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

7. Appliances
E.g. Hearing Aids, Wheelchairs and calipers etc.

Subject to pre-authorisation

100% of Negotiated Tariff*
Limited to R 5 908 per family per annum
Paid from Risk Pool subject to sub limit
.

In & Out of Hospital – PMB’s only

100% of Negotiated Tariff*
Limited to R 6 215 per family per annum
Paid from Risk Pool subject to sub limit
.
In & Out of Hospital – PMB’s only

  • Blood Pressure Monitors Subject to a sub-limit of R550 for beneficiaries registered for Hypertension

 

Rand sub limit increased by 5.2%

 

 

Introduction of Blood Pressure Monitors

 

OTHER BENEFITS

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

8.1 Air/Road Ambulance & Emergency Services

The Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred.


100% of Scheme Tariff*
24-hour access to Call Centre including telephonic Nurse advise line

Emergency:
Subject to pre-authorisation within 72 hours after the emergency.
Inter-hospital transfers must be done by preferred service provider only.

  • Emergency response by road or air to scene of incident and Transfer from scene, to closest, most appropriate facility
  • Escort return of stranded minors can be arranged

Non-emergency:
Subject to pre-authorisation beforehand.

  • Facilitation of medically justified inter-facility transfers
  • Medical repatriation

 

100% of Scheme Tariff*
24-hour access to Call Centre including telephonic Nurse advise line

Emergency:
Subject to pre-authorisation within 72 hours after the emergency.
Inter-hospital transfers must be done by preferred service provider only.

  • Emergency response by road or air to scene of incident and Transfer from scene, to closest, most appropriate facility
  • Escort return of stranded minors can be arranged

Non-emergency:
Subject to pre-authorisation beforehand.

  • Facilitation of medically justified inter-facility transfers
  • Medical repatriation

 

8.2 Psychology & Psychiatry Treatment
Subject to PMB’s and referral from GP or Specialist, failure to do so will result in no payment.
Subject to confirmed diagnosis, treatment plan and managed care protocols



100% of Scheme Tariff*
Subject to PMB conditions only

Non-PMB’s paid from MSA*

100% of Scheme Tariff*
Subject to PMB conditions only

Non-PMB’s paid from MSA*

 

8.3 Infertility
Subject to PMB’s at State/Public Facilities



100% of Scheme Tariff*
Subject to PMB conditions only at State/Public Facilities
Non-PMB’s paid from MSA*

100% of Scheme Tariff*
Subject to PMB conditions only at State/Public Facilities
Non-PMB’s paid from MSA*

 

8.4 Hospice and Private Nursing

Subject to PMB’s, pre-authorisation and protocols.



100% of Negotiated Tariff*
Subject to PMB conditions only

Non-PMB’s paid from MSA*

100% of Negotiated Tariff*
Subject to PMB conditions only

Non-PMB’s paid from MSA*

 

HOSMED BAMBINO PROGRAM
Hosmed cares about its maternity mothers and this program aims to assist them during this time by providing advice and benefits.

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

9.1 Hosmed Bambino Program
Subject to Registration on Hosmed Bambino Program.
At 7 months of maternity the Scheme offers a free maternity bag.


100% of Scheme Tariff*
PMB Based on Protocols
Admissions only at DSP* Hospital Network.

100% of Scheme Tariff*
PMB Based on Protocols
Admissions only at DSP* Hospital Network.

 

9.2 Hospital Confinement:



NVD – Limited to 2 days
Caesarean – Limited to 3 days

NVD – Limited to 2 days
Caesarean – Limited to 3 days

 

9.3 Home Delivery:
By Registered Midwife pre-authorisation required



Limited to R 4 220/pregnancy.  100% of Negotiated Tariff

Limited to R 4 439/pregnancy.  100% of Negotiated Tariff

Rand sub limit increased by 5.2%

9.4 Maternity Ultrasounds(s):



Limited to 2 2D ultrasounds per pregnancy for In and Out of Hospital

Limited to 2 2D ultrasounds per pregnancy for In and Out of Hospital

 

9.5 Maternity Visit(s):



Additional 7 GP consultations and 2 specialist consultations per Pregnancy at GP or Specialist (in addition to normal consultation limit)

Additional 7 GP consultations and 2 specialist consultations per Pregnancy at GP or Specialist (Once these limits have been reached further ante-natal consultations will be paid from the day-to-day benefit)

Wording amended

9.6 Antenatal Pathology Screening:
Haemoglobin, Syphilis, Chlamydia, Bacteriuria, Hepatitis B and Rhesus incompatibility



No Benefit

100% Scheme Tariff*

Introduction of Antenatal Pathology Screening

9.7 Antenatal Classes:
By Registered Nurse



No Benefit

No Benefit

 

9.8 Immunisation benefit



Immunisation as per the Immunisation schedule by the Department of Health up to 6 months of age

Immunisation as per the Immunisation schedule by the Department of Health up to 12 months of age

Immunisations increased to 12 months of age

HOSMED WE CARE

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

10.1 Wellness Programme


100% of Scheme Tariff*

  • 1 Free Pap Smear for Females over 18 Years per beneficiary per Annum
  • 1 Free Mammogram for Females over 40 Years per beneficiary per Annum
  • 1 Free PSA for Males over 40 Years per beneficiary per Annum
  • 1 Free Cholesterol Test over 20 Years per beneficiary per Annum
  • 1 Free Flu Vaccine per beneficiary per Annum
  • 1 Free Blood Sugar Test over 15 Years per beneficiary per Annum
  • 1 Free BP check per beneficiary per Annum
  • 1 Free HIV Test per beneficiary per Annum
  • Free HPV vaccination per beneficiary between 9 and 12 years of age

100% of Scheme Tariff*

  • 1 Free Pap Smear for Females over 18 Years per beneficiary per Annum
  • 1 Free Mammogram for Females over 40 Years per beneficiary per Annum
  • 1 Free PSA for Males over 40 Years per beneficiary per Annum
  • 1 Free Cholesterol Test over 20 Years per beneficiary per Annum
  • 1 Free Flu Vaccine per beneficiary per Annum
  • 1 Free Blood Sugar Test over 15 Years per beneficiary per Annum
  • 1 Free BP check per beneficiary per Annum
  • 1 Free HIV Test per beneficiary per Annum
  • Free HPV vaccination per beneficiary between 9 and 12 years of age
  • 1 Free Pneumococcal Vaccine per beneficiary above 65 Years of age per Annum
Introduction of Pneumococcal vaccination

10.2 HIV/AIDS Management Programme
Benefits are subject to PMB’s and registration on the Scheme’s programme



100% of Scheme Tariff*

Treatment is subject to the treatment care plan and clinical protocols

100% of Scheme Tariff*

Treatment is subject to the treatment care plan and clinical protocols

 

10.3 Chronic Disease Management Programme (CDL)

Benefits are subject to registration on the Scheme’s programme



100% of Scheme Tariff*

Treatment is subject to the treatment Care plan and clinical protocols per CDL

100% of Scheme Tariff*

Treatment is subject to the treatment Care plan and clinical protocols per CDL
 

OVERALL ANNUAL LIMIT OUT OF HOSPITAL

OPTION

ACCESS 2018 ACCESS 2019

INCREASES / CHANGES

11.  Overall Annual Limit on Out of Hospital Benefits For:
 
3.1 Acute Medicines
5.3 Advanced Dentistry
6.1   Alternative Services (Homeopathy,
         Naturopathy etc)
6.2   Remedial & Other Therapies
         (Audiology, Dieticians etc),                                                            
6.3 Biokinetics & Physiotherapy

8.2 Psychology & Psychiatry Treatment


None

None



  • Scheme Tariff*:            As defined in Rule 4.9.68

“the Tariff determined or adopted by the Board in respect of the payment for healthcare services rendered to Beneficiaries by service providers who are not subject to a DSP* Tariff or a Negotiated Tariff, determined using the 2006 National Health Reference Price List (NHRPL) with the application of a year on year inflationary increase, as contemplated in Rule 15.11”

  • DSP*:                             As defined in Rule 4.9.28

“Designated Service Provider”

  • DSP Tariff*:                   As defined in Rule 4.9.29

“The fee determined in terms of an agreement between the Scheme and a service provider or a group of service providers in respect of the payment for the relevant health services”

  • Negotiated Tariff*:     As defined in Rule 4.9.54

“a Tariff negotiated and agreed ad hoc for services rendered between the Scheme and a healthcare service provider for services rendered by the relevant service provider to the Scheme or to Beneficiaries and which is different from the Scheme Tariff;”

  •  Reference Price*:        As defined in Rule 4.9.66

“The maximum reimbursable price for a list of generically similar or therapeutically equivalent products with a cost lower than that of the original medicine.” 

  • Formulary*:                  As defined in Rule 4.9.38

“A list of medicines that the Scheme will pay for the treatment of acute and chronic conditions as per the benefit option the member has selected”

  • Co-payment*:               As defined in Rule 4.9.21

“a specified rand amount a beneficiary will be liable to self-fund for the cost of a specified medical treatment as stipulated in the benefits per option”

  • Deductible*:                 As defined in Rule 4.9.26

 “A specific percentage or rand amount of the total hospital account related to a specific procedure as stipulated in the benefits per option that the beneficiary is liable for”

  • ICON*:                           Independent Clinical Oncology Network

Contributions

CONTRIBUTIONS EFFECTIVE 01 JANUARY 2019
Monthly Income
R 0 +            (Risk)
R 0 +            (Savings)
R 0 +            (Total)
Member
R 1 885
R 471
R 2 356
Adult
R 1 623
R 406
R 2 029
Child*
R 366
R 92
R 458

Premium penalties for persons joining late in life:

Premium penalties will be applied in respect of persons over the age of 35 years, who were without medical scheme cover for the period indicated hereunder after the age of 35 years as follows:

  • 1 - 4                                    @            0.05 multiplied by the relevant contribution above
  • 5 - 14                                  @            0.25 multiplied by the relevant contribution above
  • 15 - 24                                @            0.50 multiplied by the relevant contribution above
  • 25 + years                          @            0.75 multiplied by the relevant contribution above

 

creditable coverage” means any period of verifiable medical scheme membership of the applicant or his or her dependant, but excluding membership as a child dependant, terminating two years or more before the date of the latest application for membership.  Any years of creditable coverage which can be demonstrated by the applicant or his or her dependant shall be subtracted from his or her current age in determining the applicable penalty.       

Chronic Disease List 2019

The CDL list consists of the chronic conditions listed below:

  • Addison’s Disease
  • Asthma
  • Bipolar Mood Disorder
  • Bronchiectasis
  • Cardiac Failure
  • Cardiomyopathy
  • Chronic Renal Disease
  • Chronic Obstructive Pulmonary Disease
  • Coronary Artery Disease
  • Crohn’s Disease
  • Diabetes Insipidus
  • Diabetes Mellitus Type I
  • Diabetes Mellitus Type II
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • HIV/AIDS
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple Sclerosis
  • Parkinson’s Disease
  • Rheumatoid Arthritis
  • Schizophrenia
  • Systemic Lupus Erythematosus
  • Ulcerative Colitis

Exclusions

PRESCRIBED MINIMUM BENEFITS

The Scheme will pay in full, without co-payment or use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefits as per Regulation 8 of the Act. Furthermore, where a protocol or a formulary drug preferred by the scheme has been ineffective or would cause harm to a beneficiary, the scheme will fund the cost of the appropriate substitution treatment without a penalty to the beneficiary as required by regulation 15H and 15I of the Act.

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PMB's

PRESCRIBED MINIMUM BENEFITS

Designated service providers (DSP)

A healthcare provider or group of providers selected by the Scheme as preferred provider(s) to provide to the Beneficiaries, diagnosis, treatment and care in respect of one or more Prescribed Minimum Benefit conditions.

The service provider(s) designated by the Scheme for the delivery of Prescribed Minimum Benefits to its Beneficiaries are those providers in respect of whom the Scheme has entered into an agreement with. Beneficiaries can obtain information, including whether a service provider is a DSP, by communicating and requesting such information from the Scheme

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Medical Savings Account

ACCESS OPTION

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