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Health Plans | Essential

Benefits Essential Option 2020

OPTION

ESSENTIAL 2019 ESSENTIAL 2020
Overall Annual Limit

Limited to PMB conditions only for in and out of hospital benefits

Subject to sub limits not being exceeded

Limited to PMB conditions only for in and out of hospital benefits

Subject to sub limits not being exceeded

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)

No Benefit


No Benefit

 

Benefits (In hospital)

HOSPITALISATION AND ASSOCIATED COSTS – PROVINCIAL AND PRIVATE

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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

Limited to PMB conditions only

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

Private 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

Limited to PMB conditions only

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*

Limited to PMB conditions only

100% of DSP Tariff*
TTO benefit for 7 days.
Subject to formulary*

Limited to PMB conditions only

1.02 Surgical Procedures including GP and Specialist Consultations.

Subject to Pre-authorisation and PMB’s


100% of Scheme Tariff*

Limited to PMB conditions only

100% of Scheme Tariff*

Limited to PMB conditions only

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.

All specialised radiology subject to pre-authorisation.

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

Combined limited of R 5 883 per beneficiary per annum
Pathology and Radiology: Network Provider Only. Limited to PMB conditions only

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

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

Limited to PMB conditions only
Combined limited of R 6 177 per beneficiary per annum

Pathology and Radiology: Network Provider Only. Limited to PMB conditions only
Specialised Radiology:
MRI/PET/CAT Scans Limited to 2 per beneficiary per annum for In and Out Hospital.
Limited to PMB conditions only

1.04 Blood Transfusions

100% of Scheme Tariff*
Limited to PMB conditions only

100% of Scheme Tariff*
Limited 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*
Limited to PMB conditions only
Subject to 21 Days per beneficiary or up to

15 out-patient contacts per annum

100% of Scheme Tariff*
Limited to PMB conditions only

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

100% of Scheme Tariff*

Limited to R 12 353 per family per annum
PMB based on clinical protocols
Limited to PMB conditions only

1.08 Organ Transplants

Subject to PMB’s and pre-authorisation


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

Limited to PMB conditions only

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

Limited to PMB conditions only

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

100% of Scheme Tariff*
Limited to PMB conditions only
Subject to pre-authorisation

100% of Scheme Tariff*
Limited 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*.

Limited to PMB conditions only

100% of Negotiated Tariff*
Unlimited benefits for PMB admissions and PMB level of Care
Subject to Treatment Protocols and formulary*.

Limited to PMB conditions only

1.11 Sterilisation/Vasectomy

Subject to pre-authorisation


100% of Scheme Tariff*

Limited to PMB conditions only

100% of Scheme Tariff*

Limited 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 18 706 per family per Annum

Limited to PMB conditions only

Sub Limit:
Limited to PMB conditions only

 

 

 

Excluded unless PMB. Prosthesis limited to equivalent available in the state.

 

Subject to PMB

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

Maximum R 8 879 subject to overall limit

Subject to overall prosthesis limit. PMB UPFS rates applicable

100% of Negotiated Tariff*
Limited to R 19 641 per family per annum

 

Sub-Limits:
Limited to PMB conditions only

 

 

 

Excluded unless PMB. Prosthesis limited to equivalent available in the state.

 

Subject to PMB

 

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

 

No benefit

 

 

No Benefit

 

No Benefit

 

Maximum R 9 323 subject to overall limit

Subject to overall prosthesis limit.

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*

Limited to PMB conditions only

100% of Scheme Tariff*

Limited 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*

Limited to PMB conditions only

100% of Scheme Tariff*

Limited 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 PMB conditions only

100% of Negotiated Tariff*

Limited to PMB conditions only

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

100% of Negotiated Tariff*

Limited to PMB conditions only

100% of Negotiated Tariff*

Limited to PMB conditions only

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

100% of Negotiated Tariff*

Limited to PMB conditions only

100% of Negotiated Tariff*

Limited to PMB conditions only

1.18 Circumcision
Subject to pre-authorisation

100% of DSP Tariff* at DSP* GP or 100% of Scheme Tariff* at Specialist
Out of Hospital Only
Limited to PMB conditions only

100% of DSP Tariff*Limited to PMB conditions only

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

100% of Negotiated Tariff*
Limited to PMB conditions only as per public hospital protocols

100% of Negotiated Tariff*
Limited to PMB conditions only as per public hospital protocols

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

100% of Negotiated Tariff*

Limited to PMB conditions only

100% of Negotiated Tariff*

Limited to PMB conditions only

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

Limited to PMB conditions only

Limited to R633 per fill and 4 fills per eye per annum

Limited to PMB conditions only

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

Limited to PMB conditions only 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

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

Refer to Scheme Exclusion list

No Benefit

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

 

No Benefit

1.25 Exclusions for Hospital Admissions & Treatment Related to:
(In conjunction with the Overall Scheme Exclusion List and subject to PMB’s)

 

Refer to Scheme Exclusion list

1.26 Deductible* Applied for In-Hospital Procedures

 

Not applicable

DAY HOSPITAL PROCEDURES

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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

co-payment* still applicable to defined conditions above

Subject to Scheme Tariff*

Subject to PMB conditions only:

  1. Biopsy
  2. Breast Biopsy
  3. Cataract
  4. Colonoscopy
  5. Cone Biopsy/ Colposcopy
  6. Cystoscopy
  7. ERCP
  8. Excision of Extensive Skin lesions /Repair/Skin Graft
  9. Gastroscopy or Colonoscopy or Oesophagoscopy
  10. Haemorrhoidectomy
  11. Hysteroscopy, D&C, Minor Gynaecological Procedures
  12. Myringotomy / Grommets
  13. Repair of Wounds
  14. Termination of Pregnancy
  15. Tonsillectomy and Adenoidectomy
  16. Umbilical and Inguinal Hernia

Subject to Scheme Tariff*

Subject to PMB conditions only:

  1. Biopsy
  2. Breast Biopsy
  3. Cataract
  4. Colonoscopy
  5. Cone Biopsy/ Colposcopy
  6. Cystoscopy
  7. ERCP
  8. Excision of Extensive Skin lesions /Repair/Skin Graft
  9. Gastroscopy or Colonoscopy or Oesophagoscopy
  10. Haemorrhoidectomy
  11. Hysteroscopy, D&C, Minor Gynaecological Procedures
  12. Grommets
  13. Repair of Wounds
  14. Termination of Pregnancy
  15. Umbilical and Inguinal Hernia

Benefits (Out of hospital)

GENERAL PRACTITIONERS AND SPECIALIST

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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

100% of DSP Tariff*
General Practitioners Consultations:
DSP* GP
Unlimited visits & acute medication from any GP within the DSP* Network at 100% of DSP Tariff*

100% of Scheme Tariff*
Specialist Consultations:
Limited to 3 Visits per family per annum only on referral from DSP* GP.
Subject to pre-authorisation
Limited to PMB conditions only

100% of DSP Tariff*

General Practitioner Consultations:
DSP* GP
100% of DSP Tariff*
Unlimited visits & acute medication from any GP within the DSP* Network at 100% of DSP* Tariff*

Specialist Consultations:
100% of Scheme Tariff*
Limited to 3 Visits per family per annum only on referral from DSP* GP.
Subject to pre-authorisation
Limited to PMB conditions only

2.2 Diagnostic Investigations
Subject to PMB’s and protocols.

All specialised radiology subject to pre-authorisation.

100% of DSP* Tariff*
Pathology:
Limited to R 822 per beneficiary per annum
Network Provider Only
Limited to PMB conditions only

Radiology:
Limited to R 822 per beneficiary per annum
Referral by Network Provider Only
Limited to PMB conditions only

Specialised Radiology:
MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum and Limited to 1.03
Subject to pre-authorisation
Referral by Network Provider Only
Limited to PMB conditions only

100% of DSP Tariff*

Pathology:
Limited to R 863 per beneficiary per annum
Network Provider Only
Limited to PMB conditions only

Radiology:
Limited to R 863 per beneficiary per annum
Referral by Network Provider Only
Limited to PMB conditions only

Specialised Radiology:
MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum and Limited to 1.03
Subject to pre-authorisation
Referral by Network Provider Only

Limited to PMB conditions only

MEDICINES & INJECTION MATERIAL

OPTION

ESSENTIAL 2019 ESSENTIAL 2020
3.1 Acute Medicines


 

100% of Reference Price*

DSP* GP
Unlimited Acute Medication dispensed by the DSP* GP
Subject to Medicine formulary* and Protocols, Including Materials.

Homeopathic Medication excluded

Acute Medication Obtained from Pharmacy:
R 1 206 per beneficiary limited to
R 3 366 per family per annum

100% of Reference Price*
DSP* GP
Unlimited Acute medication dispensed by the DSP* GP

Subject to Medicine formulary* and Protocols, Including Materials.

Homeopathic Medication excluded

Acute Medication Obtained from Pharmacy:
R 1 266 per beneficiary limited to
R 3 534 per family per annum

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
Subject to pre-authorisation by Designated Service Provider,
Treatment Protocols, Medicine Formulary* and Registration of the Chronic Medicine by the DSP* GP.

Provider Network Only


100% of Reference Price*
Unlimited

Subject to pre-authorisation by Designated Service Provider, Treatment Protocols, Medicine formulary* and Registration of the Chronic Medicine by the DSP* GP.

Provider Network Only

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*

Limited to R 615 per Family per annum
Maximum R 90 per script. Subject to Acute Medication limit 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


No Benefit

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*

Limited to R 61 per beneficiary per month, subject to R 732 per family per annum. Subject to oral and injectable contraceptives only
Subject to the contraceptive formulary*

100% of Reference Price*

Limited to R 646 per Family per annum
Maximum R 95 per script.
Subject to the contraceptive formulary*

3.5 Contraceptive benefit

 

100% of Reference Price*

Limited to R 64 per beneficiary per month, subject to R 767 per family per annum. Subject to oral and injectable contraceptives only

Subject to the contraceptive formulary*


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

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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*

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

100% of DSP Tariff*

R 185 per lens – clear single vision
or
R 420 per lens – clear bifocal
or
R 420 per lens – base multifocal
No Benefit for Fixed Tints

No benefit for contact lenses if spectacles purchased

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*
R 585 per beneficiary every 24 months
No claim for spectacles if contact lenses purchased.
One claim per beneficiary every 24 months
Provider Network Only

100% of DSP Tariff*
R 615 per beneficiary every 24 months

No benefit for spectacles if contact lenses purchased.
Provider Network Only

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*

R300 per beneficiary

100% of DSP Tariff*

R 300 per beneficiary

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*
One comprehensive consultation per beneficiary every 24 months

100% of DSP Tariff*
One comprehensive consultation per beneficiary every 24 months

DENTISTRY BENEFIT

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

5.1 Conservative Dentistry (Dentist and Dental therapist)


 

100% of Scheme Tariff*
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*

Consultations, Fillings, Extractions

Preventative scale and polish.
Fluoride treatment limited to beneficiaries below the age of 12 years

Conscious sedation for children up to 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.


Limited to PMB conditions only
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

Limited to PMB conditions only

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

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

Limited to PMB conditions only

Limited to PMB conditions only

AUXILIARY BENEFIT

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

6.1 ALTERNATIVE SERVICES
Homeopathy, Naturopathy, Chiropractor and Podiatry

Limited to PMB conditions only

No Benefit

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

Limited to PMB conditions only and clinical protocols
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.
Limited to PMB conditions only

6.3 PHYSIOTHERAPY OUT OF HOSPITAL Biokinetics & Physiotherapy



 

Limited to PMB conditions only and clinical protocols

 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 for back pain

APPLIANCES

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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

Subject to pre-authorisation

100% of Negotiated Tariff*
Limited to R 2 775 per family per annum

In and Out of Hospital
Limited to PMB conditions only

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

100% of Negotiated Tariff*
Limited to R 2 914 per family per annum

 In and Out of Hospital
Limited to PMB conditions only

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

OTHER BENEFITS

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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 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 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



Limited to PMB conditions only

Limited to PMB conditions only

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



Limited to PMB conditions only at State/Public Facilities.

Limited to PMB conditions only

8.4 Hospice and Private Nursing

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



100% of Negotiated tariff*

Limited to PMB conditions only

100% of Negotiated Tariff*

Limited to PMB conditions only

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

ESSENTIAL 2019 ESSENTIAL 2020

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 4 439/pregnancy. 
100% of Negotiated Tariff*

Limited to R 4 661/pregnancy. 
100% of Negotiated Tariff*

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):



100% of Scheme Tariff*
Subject to DSP* GP and Specialist consultation limit as per 2.1

100% of Scheme Tariff*
Subject to DSP* GP and Specialist consultation limit as per 2.1

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



100% Scheme Tariff*

100% of Scheme Tariff*

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 12 months of age

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

HOSMED WE CARE

OPTION

ESSENTIAL 2019 ESSENTIAL 2020

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 Blood Pressure 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

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 Blood Pressure 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

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

ESSENTIAL 2019 ESSENTIAL 2020

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

    Voluntarily*:               Of one’s own free will.

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