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Health Plans | Value

Benefits Value Option 2019

OPTION

VALUE 2018 VALUE 2019

INCREASES / CHANGES

Overall Annual Limit

No Overall Annual Limit

Subject to sub limits not being exceeded

No Overall Annual Limit

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)

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

VALUE 2018 VALUE 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
100% of Scheme Tariff*

Unlimited benefits subject to pre-authorisation, clinical protocols and formulary*

Private and State Hospitals
100% of Scheme Tariff*

Unlimited benefits subject to pre-authorisation, clinical protocols and formulary*

 

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

100% of Scheme Tariff*
TTO benefit for 7 days.

Subject to formulary*

100% of Scheme Tariff*
TTO benefit for 7 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* 100% of Scheme Tariff*

 

1.04 Blood Transfusions

100% of Scheme Tariff* 100% of Scheme Tariff*

 

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 R 260 585 per beneficiary per annum

PMB & Non-PMB Oncology treatment based on DSP* ICON* Standard Protocols

100% of DSP Tariff*
Limited to R 274 135 per beneficiary per annum

PMB & Non-PMB Oncology treatment based on DSP* ICON* Standard Protocols

Rand sub limit increased by 5.2%

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 21 Days per beneficiary or up to 15 out-patient contacts per annum  (Subject to PMB’s)
Non PMB’s – 14 days per family subject to a limit of R 18 568
Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan.

100% of Scheme Tariff*
Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum  (Subject to PMB’s)
Non PMB’s – 14 days per family subject to a limit of R 19 534
Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan.

Rand sub limit increased by 5.2%

1.07 Drug & Alcohol Rehabilitation

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


100% of Scheme Tariff*
Limited to R 17 513 per family per annum

100% of Scheme Tariff*
Limited to R 18 424 per family per annum

Rand sub limit increased by 5.2%

1.08 Organ Transplants

Subject to PMB’s and pre-authorisation


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

100% of 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*
Anaesthetist and Hospital cost is payable from hospital benefit.  Specialist fee subject to available Advanced Dentistry Benefit.
Benefit is payable from hospital benefit only in the following cases:

  • Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved
  • Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only

 

100% of Scheme Tariff*
Anaesthetist and Hospital cost is payable from hospital benefit.  Specialist fee subject to available Advanced Dentistry Benefit.
Benefit is payable from hospital benefit only in the following cases:

  • Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved
  • Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only

 

1.09.1 Maxillo-facial and Oral Surgery                                



100% of Scheme Tariff*
Maxillo-facial and oral surgery limited to symptomatic wisdom teeth and surgical exposures. Implants limited to being clinically approved as part of a PMB condition and treatment plan
Anaesthetist and Hospital cost is payable from hospitalisation:
Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only.

All other procedures subject to PMB only

100% of Scheme Tariff*
Maxillo-facial and oral surgery limited to symptomatic wisdom teeth and surgical exposures. Implants limited to being clinically approved as part of a PMB condition and treatment plan
Anaesthetist and Hospital cost is payable from hospitalisation:
Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only.

All other procedures subject to PMB only

 


1.10 Renal Dialysis

Subject to PMB’s and to pre-authorisation

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

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

 

1.11 Sterilisation/Vasectomy

Subject to pre-authorisation


100% of Scheme Tariff*
Sterilisation limited to R 13 715 per beneficiary per annum
Vasectomy co-payment* of R 1 298 if procedure is done under General Anaesthetic in Major Theatre.

100% of Scheme Tariff*
Sterilisation limited to R 14 428 per beneficiary per annum
Vasectomy co-payment* of R 1 365 if procedure is done under General Anaesthetic in Major Theatre.

Rand sub limit increased by 5.2%

Rand sub limit increased by 5.2%


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 R43 446 per family per annum.

Sub-Limits:
Limited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols. R21 100 per level subject to overall limit not being exceeded. Maximum 1 event per beneficiary per annum

R 5 000 co-payment* applicable for all non-PMB spinal surgery

R39 035 per annum. Subject to the overall limit and maximum of one procedure per beneficiary per annum. Excludes cement

R5 166 per lens

1 per lesion-maximum 3 lesions
Bare metal stents: R12 660 per stent
Drug eluting stents: R17 935 per stent

Subject to overall prosthesis limit and PMB protocols

Subject to State hospital protocols and PMB for secondary prevention only. Overall limits apply for primary prevention

 

 

Subject to overall prosthesis benefit

No benefit

 

Subject to overall limit for prosthesis benefit

Children under 7 years of age only. Subject to clinical protocols and overall limit

Maximum R12 660 subject to overall limit

100% of Negotiated Tariff*
Limited to R45 705 per family per annum.

Sub-Limits:
Limited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols. R22 197 per level subject to overall limit not being exceeded. Maximum 1 event per beneficiary per annum

R 5 000 co-payment* applicable for all non-PMB spinal surgery

R39 035 per annum. Subject to the overall limit and maximum of one procedure per beneficiary per annum. Excludes cement

R5 435 per lens

1 per lesion-maximum 3 lesions
Bare metal stents: R13 318 per stent
Drug eluting stents: R18 868 per stent

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

Subject to overall prosthesis benefit

No benefit

 

Subject to overall limit for prosthesis benefit

Children under 7 years of age only. Subject to clinical protocols and overall limit

Maximum R13 318 subject to overall limit

Rand sub limit increased by 5.2%

 

 

Rand sub limit increased by 5.2%

 

 

Rand sub limit increased by 5.2%

 

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*

100% of Scheme Tariff*

 

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*

100% of Scheme Tariff*

 


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*

Limited to 14 days per beneficiary per annum

100% of Negotiated Tariff*

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*

In and Out of hospital

100% of Scheme Tariff*

In and Out of hospital

 

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

50% of Scheme Tariff*
Limited to R 38 508 per family per annum

50% of Scheme Tariff*
Limited to R 40 510 per family per annum

Rand sub limit increased by 5.2%

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

100% of Negotiated Tariff*
Limited to R 24 265 per family per annum

100% of Negotiated Tariff*
Limited to R 25 527 per family per annum

Rand sub limit increased by 5.2%

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

Limited to 4 fills per eye per annum

Limited to R 633 per fill

Limited to 4 fills per eye per annum

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

Rand sub limit increased by 5.2%

Limitation on number of fills included

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

100% of Scheme Tariff*

Fusion, Laminectomy and Discectomy:

R 5 000 co-payment* applicable for all non-PMB spinal surgery

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

If the patient fails to comply with the conservative treatment protocol and goes for surgery without authorisation a co-payment* of 30% on accommodation, medicines, consultations and procedures is applicable.

100% of Scheme Tariff*

Fusion, Laminectomy and Discectomy:

R 5 000 co-payment* applicable for all non-PMB spinal surgery

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

If the patient fails to comply with the conservative treatment protocol and goes for surgery without authorisation a co-payment* of 30% on accommodation, medicines, consultations and procedures is applicable.

 

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*

100% of Scheme Tariff*

 

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

100% of Scheme Tariff*

Laparoscopic Hospitalisation & Associated costs will attract a R5 000 except for the following circumstances where no co-payment* will apply:

  • Purely diagnostic laparoscopy
  • Aspiration/excision ovarian cyst
  • Lap-apendicectomy for females
  • Repair of recurrent or bilateral inguinal hernias

100% of Scheme Tariff*

Laparoscopic Hospitalisation & Associated costs will attract a R5 000 except for the following circumstances where no co-payment* will apply:

  • Purely diagnostic laparoscopy
  • Aspiration/excision ovarian cyst
  • Lap-apendicectomy for females
  • Repair of recurrent or bilateral inguinal hernias

 

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 Refer to Scheme Exclusion list

 

1.26 Deductible* of R5000 will apply to the below procedures in-hospital except for PMB Conditions

  • Joint Replacement
  • Umbilical Hernia Repair
  • Hysterectomy
  • Functional Nasal Surgery
  • Elective caesarean section
  • Joint Replacement
  • Umbilical Hernia Repair
  • Hysterectomy
  • Functional Nasal Surgery
  • Elective caesarean section

 

Benefits (Out of hospital)

GENERAL PRACTITIONERS AND SPECIALIST

OPTION

VALUE 2018 VALUE 2019

INCREASES / CHANGES

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

100% of Scheme Tariff*

General Practitioner Consultations:
10 GP Visits per Beneficiary
Limited to 20 GP Visits per Family per Annum.

Specialist Consultations:
Member:  3 Visits
Member + 1 = 5 Visits
Member + 2 + = 7 Visits

Specialist consultations require GP referral or payment will made at GP rates, except for:

  • Paediatricians
  • Gynaecologists

100% of Scheme Tariff*

General Practitioner Consultations:
10 GP Visits per Beneficiary
Limited to 20 GP Visits per Family per Annum.

Specialist Consultations:
Member:  3 Visits
Member + 1 = 5 Visits
Member + 2 + = 7 Visits

Specialist consultations require GP referral or payment will made at GP rates, except for:

  • Paediatricians
  • Gynaecologists
 

2.2 Diagnostic Investigations
Subject to PMB’s and protocols.

All specialised radiology subject to pre-authorisation.

100% of Scheme Tariff*

Pathology:
Limited to R 2 516 per beneficiary per annum

Radiology:
Limited to R 1 957 per beneficiary per annum

MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum
Subject to pre-authorisation

100% of Scheme Tariff*

Pathology:
Limited to R 2 647 per beneficiary per annum

Radiology:
Limited to R 2 059 per beneficiary per annum

MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum
Subject to pre-authorisation

Rand sub limit increased by 5.2%

 

Rand sub limit increased by 5.2%

MEDICINES & INJECTION MATERIAL

OPTION

VALUE 2018 VALUE 2019

INCREASES / CHANGES

3.1 Acute Medicines


 

100% of Reference Price*

Limited to R 3 207 per beneficiary and R 6 509 per family per annum

Subject to medicine formulary* and Protocols, including Materials

Homeopathic Medication excluded

100% of Reference Price*

Limited to R 5 183 per beneficiary and R 10 520 per family per annum

Subject to medicine formulary* and Protocols, including Materials

Homeopathic Medication excluded

Rand sub limit increased by 61.62%

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, treatment protocols and medicine formulary*.

Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries.

Benefit Initially payable from limit 3.3 below.


100% of Reference Price*
Unlimited
Subject to pre-authorisation, treatment protocols and medicine formulary*.

Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries.

Benefit Initially payable from limit 3.3 below.



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*

R 6 262 per beneficiary Limited to
R 12 639 per family per annum

Subject to pre-authorisation, treatment protocols and medicine formulary*

Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries


100% of Reference Price*

R 6 588 per beneficiary Limited to
R 13 296 per family per annum

Subject to pre-authorisation, treatment protocols and medicine formulary*

Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries.


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

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 R633 per family per annum
Maximum R142 per script
Included in Limit 3.1 above


100% of Reference Price*

Limited to R1 925 per family per annum
Maximum R150 per script
Included in Limit 3.1 above

Rand sub limit increased by 204.11%
Rand sub limit increased by 5%
Wording amended

3.5 Contraceptive benefit

100% of Reference Price*

Limited to R 106 per beneficiary per month, subject to R 1 266 per family per annum. Subject to oral, injectable and patch contraceptives only

Subject to the contraceptive formulary*

100% of Reference Price*

Limited to R 112 per beneficiary per month, subject to R 1 332 per family per annum. Subject to oral, injectable and patch 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

VALUE 2018 VALUE 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 *

R 175 per lens – clear single vision
or
R 380 per lens – clear bifocal
or
R 380 per lens – base multifocal
Fixed tints up to 35%

No benefit for contact lenses if spectacles purchased

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
Fixed tints up to 35%

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*
R 1 810 per beneficiary every 24 months
No claim for spectacles if contact lenses purchased.

One claim per beneficiary every 24 months

100% of DSP Tariff*
R 1 810 per beneficiary every 24 months
No claim for spectacles if contact lenses purchased.

One claim per beneficiary every 24 months

Wording amended

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*
R 580 per beneficiary

100% of DSP Tariff*
R 795 per beneficiary

Wording amended
Rand sub limit increased by 37.07%

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

Wording amended

DENTISTRY BENEFIT

OPTION

VALUE 2018 VALUE 2019

INCREASES / CHANGES

5.1 Conservative Dentistry (Dentist and Dental therapist)


 

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

 

X-rays intra-oral covered
Panoramic Radiographs limited to 1 per beneficiary every 24 months

Subject to treatment protocols and pre-authorisation for extensive treatment

100% of Scheme Tariff*
Unlimited
Consultations, Fillings, Extractions, Root canal treatment two (2) RCT family per year, Preventative scale and polish.
Fluoride treatment limited to beneficiaries below the age of 12 years

X-rays intra-oral covered
Panoramic Radiographs limited to 1 per beneficiary every 24 months

Subject to treatment protocols and pre-authorisation for extensive treatment

Introduction of root canal treatment

 

5.2 Advanced Dentistry

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

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


100% of Scheme Tariff*
R 4 030 per beneficiary limited to R 5 760 per family per annum.
Crowns and Bridges Root canal, Impacted wisdoms and Orthodontics

Acrylic (Plastic) Dentures
Subject to above available limit.
Limited to 1 per beneficiary every 4 years

100% of Scheme Tariff*
R 4 240 per beneficiary limited to R 6 060 per family per annum.
Crowns and Bridges, Impacted wisdoms and Orthodontics

Dental Implants
Two (2) implants per family once every five years per beneficiary
Limited to R3 000 per implant subject to above available limit.

Partial Metal Frame Dentures
Limited to one (1) set per beneficiary every 5 years.

Acrylic (Plastic) Dentures
Subject to above available limit.
Limited to 1 per beneficiary every 4 years

Rand sub limit increased by 5.2%

Root Canal removed

 

Introduction of Dental Implants

 

 

Introduction of Partial Metal Frame Dentures

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

100% of Scheme Tariff*
(included in limit 5.2)
Benefit is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only.

100% of Scheme Tariff*
(included in limit 5.2)
Benefit is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only.

 

AUXILIARY BENEFIT

OPTION

VALUE 2018 VALUE 2019

INCREASES / CHANGES

6.1 ALTERNATIVE SERVICES
Homeopathy, Naturopathy, Chiropractor and Podiatry

100% of Scheme Tariff*
Collectively limited to R 3 397 per family per annum
Medicine dispensed limited to Acute Medication Limit (3.1).
Homeopathic Medication Excluded

100% of Scheme Tariff*
Collectively limited to R 3 574 per family per annum
Medicine dispensed limited to Acute Medication Limit (3.1).

Homeopathic Medication Excluded

Rand sub limit increased by 5.2%

 

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*

Collectively limited to R 3 281 per family per annum

100% of Scheme Tariff*

Collectively limited to R 3 452 per family per annum

Rand sub limit increased by 5.2%

6.3 PHYSIOTHERAPY OUT OF HOSPITAL Biokinetics & Physiotherapy

100% of Scheme Tariff

R 1 540 per beneficiary limited to R 2 553 per family per annum.

100% of Scheme Tariff

R 1 620 per beneficiary limited to R 2 686 per family per annum.

Rand sub limit increased by 5.2%

APPLIANCES

OPTION

VALUE 2018 VALUE 2019

INCREASES / CHANGES

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

Subject to pre-authorisation

100% of Negotiated Tariff*
Limited to R 12 681 per family per annum

  • Stoma Care – Subject to a sub limit of R 6 541 per family per annum
  • Wheelchairs – one claim per Beneficiary every 36 months subject to pre-authorisation.
  • Hearing aids – one claim per beneficiary every 24 months subject to pre-authorisation.

100% of Negotiated Tariff*
Limited to R 13 340 per family per annum

  • Stoma Care – Subject to a sub limit of R 6 881 per family per annum
  • Wheelchairs – one claim per Beneficiary every 36 months subject to pre-authorisation.
  • Hearing aids – one claim per beneficiary every 24 months subject to pre-authorisation.
  • Blood Pressure Monitors
  • Subject to a sub-limit of R550 for beneficiaries registered for Hypertension

 

Rand sub limit increased by 5.2%

 

Rand sub limit increased by 5.2%

 

 

 

Introduction of Blood Pressure Monitors

OTHER BENEFITS

OPTION

VALUE 2018 VALUE 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 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



100% of Scheme Tariff*

R 2 669 per beneficiary, Limited to R 6 710 per Family.

100% of Scheme Tariff*

R 2 808 per beneficiary, Limited to R 7 059 per Family.

Rand sub limit increased by 5.2%

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



100% of Scheme Tariff*

100% of Scheme Tariff*

 

8.4 Hospice and Private Nursing

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



100% of Negotiated Tariff*

Subject to combined limit of a maximum period of 14 days per annum-except for PMB’s

100% of Negotiated Tariff*

Subject to combined limit of a maximum period of 14 days per annum-except for PMB’s

 

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

VALUE 2018 VALUE 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 Clinical Protocols

100% of Scheme Tariff*
PMB Based on Clinical Protocols

 

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 5 275/pregnancy.  100% of Negotiated Tariff*

Limited to R 5 549/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 6 GP consultations and 3 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)

Additional 6 GP consultations and 3 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

VALUE 2018 VALUE 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 Colon Cancer Blood Test over 50 years per beneficiary per Annum
  • 1 Free Blood Pressure test 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 Colon Cancer Blood Test over 50 years per beneficiary per Annum
  • 1 Free Blood Pressure test 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 per CDL

100% of Scheme Tariff*

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

 

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

VALUE 2018 VALUE 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


Collectively Limited to per Family per annum:

M         -     R 8 968
M+1     -     R 18 937
M+2     -     R 20 599
M+3     -     R 22 814

Collectively Limited to per Family per annum:

M         -     R 9 434
M+1     -     R 19 922
M+2     -     R 21 670
M+3     -     R 24 000

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


  • 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 +
Member
R 3 249
Adult
R 2 376
Child*
R 553

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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